Provider Demographics
NPI:1770258188
Name:TAN, LI (PHARMD)
Entity Type:Individual
Prefix:
First Name:LI
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110B RALEIGH DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-7139
Mailing Address - Country:US
Mailing Address - Phone:917-250-0126
Mailing Address - Fax:
Practice Address - Street 1:415 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-1610
Practice Address - Country:US
Practice Address - Phone:270-358-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist