Provider Demographics
NPI:1013467885
Name:LILLY, KATIE JEAN (REGISTERED PHARM D)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:JEAN
Last Name:LILLY
Suffix:
Gender:F
Credentials:REGISTERED PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 WASHINGTON ST W
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-2319
Mailing Address - Country:US
Mailing Address - Phone:304-344-2565
Mailing Address - Fax:
Practice Address - Street 1:1719 WASHINGTON ST W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2319
Practice Address - Country:US
Practice Address - Phone:304-344-2565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0009897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist