Provider Demographics
NPI:1871830737
Name:TILL-BLOCK, LORI SUSAN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:SUSAN
Last Name:TILL-BLOCK
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 1:3306 BONITA BEACH RD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4174
Mailing Address - Country:US
Mailing Address - Phone:239-495-1700
Mailing Address - Fax:239-495-7993
Practice Address - Street 1:3306 BONITA BEACH RD
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4174
Practice Address - Country:US
Practice Address - Phone:239-495-1700
Practice Address - Fax:239-495-7993
Is Sole Proprietor?:No
Enumeration Date:2013-01-12
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0022977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist