Provider Demographics
NPI:1194813881
Name:TACKEL, LAUREN (RPH)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:TACKEL
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 1:5721 REVETON RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1355
Mailing Address - Country:US
Mailing Address - Phone:313-277-0098
Mailing Address - Fax:313-277-0208
Practice Address - Street 1:8641 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1425
Practice Address - Country:US
Practice Address - Phone:313-277-0098
Practice Address - Fax:313-277-0208
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022478183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302022478OtherPHARMACIST LICENSE NUMBER