Provider Demographics
NPI:1629255104
Name:DOMKEM, LILIANE KOMGUEM
Entity Type:Individual
Prefix:
First Name:LILIANE
Middle Name:KOMGUEM
Last Name:DOMKEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 HORSEBLOCK RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1228
Mailing Address - Country:US
Mailing Address - Phone:631-698-7914
Mailing Address - Fax:631-698-9240
Practice Address - Street 1:935 HORSEBLOCK RD
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1228
Practice Address - Country:US
Practice Address - Phone:631-698-7914
Practice Address - Fax:631-698-9240
Is Sole Proprietor?:No
Enumeration Date:2008-01-27
Last Update Date:2008-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist