Provider Demographics
NPI:1831499151
Name:TADLOCK, LEE ANNE MATHENA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:ANNE MATHENA
Last Name:TADLOCK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:LEE ANNE
Other - Middle Name:MATHENA
Other - Last Name:TADLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMC
Mailing Address - Street 1:5791 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-2831
Mailing Address - Country:US
Mailing Address - Phone:614-426-4160
Mailing Address - Fax:614-426-4170
Practice Address - Street 1:5791 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-2831
Practice Address - Country:US
Practice Address - Phone:614-426-4160
Practice Address - Fax:614-426-4170
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19781183500000X
OH31770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
46-1317638OtherTAX ID
OH1033530985OtherNPI
38-0456365OtherFEDERAL TAX ID