Provider Demographics
NPI:1578866414
Name:GILLIAM, JACY LYNN (RPH)
Entity Type:Individual
Prefix:MS
First Name:JACY
Middle Name:LYNN
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101
Mailing Address - Country:US
Mailing Address - Phone:606-324-7119
Mailing Address - Fax:606-326-0764
Practice Address - Street 1:711 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101
Practice Address - Country:US
Practice Address - Phone:606-324-7119
Practice Address - Fax:606-326-0764
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist