Provider Demographics
NPI:1336741990
Name:MANDUKU, LILLY
Entity Type:Individual
Prefix:
First Name:LILLY
Middle Name:
Last Name:MANDUKU
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 1:6360 LAKE WORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3604
Mailing Address - Country:US
Mailing Address - Phone:817-237-1118
Mailing Address - Fax:817-237-1119
Practice Address - Street 1:6360 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3604
Practice Address - Country:US
Practice Address - Phone:817-237-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist