Provider Demographics
NPI:1740876465
Name:IKELE, LILIAN IMHAZE (PHARMD)
Entity type:Individual
Prefix:
First Name:LILIAN
Middle Name:IMHAZE
Last Name:IKELE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8601
Mailing Address - Country:US
Mailing Address - Phone:347-761-2573
Mailing Address - Fax:
Practice Address - Street 1:128 W STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3221
Practice Address - Country:US
Practice Address - Phone:423-247-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist