Provider Demographics
NPI:1356422067
Name:LACKLAND LEE, CAMILLE IRIS (RPH)
Entity type:Individual
Prefix:MRS
First Name:CAMILLE
Middle Name:IRIS
Last Name:LACKLAND LEE
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 1:820 S DAMEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-7244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0051036694183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist