Provider Demographics
NPI:1952535650
Name:LILLBACK, LORI KAY
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:KAY
Last Name:LILLBACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:KAY
Other - Last Name:HOULE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:99 EDISON BLVD
Mailing Address - Street 2:SUITE L
Mailing Address - City:SILVER BAY
Mailing Address - State:MN
Mailing Address - Zip Code:55614-1211
Mailing Address - Country:US
Mailing Address - Phone:218-226-3829
Mailing Address - Fax:
Practice Address - Street 1:99 EDISON BLVD
Practice Address - Street 2:SUITE L
Practice Address - City:SILVER BAY
Practice Address - State:MN
Practice Address - Zip Code:55614-1211
Practice Address - Country:US
Practice Address - Phone:218-226-3829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN701684183700000X
MN4901-0701-0036-362183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician