Provider Demographics
NPI:1649656091
Name:IBE, LILIAN
Entity type:Individual
Prefix:
First Name:LILIAN
Middle Name:
Last Name:IBE
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 1:929 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:VIVIAN
Mailing Address - State:LA
Mailing Address - Zip Code:71082-3364
Mailing Address - Country:US
Mailing Address - Phone:318-375-4510
Mailing Address - Fax:
Practice Address - Street 1:929 S PINE ST
Practice Address - Street 2:
Practice Address - City:VIVIAN
Practice Address - State:LA
Practice Address - Zip Code:71082-3364
Practice Address - Country:US
Practice Address - Phone:318-375-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-08
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.019352183500000X
TX44770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist