Provider Demographics
NPI:1215325766
Name:LACK, LINDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:LACK
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 1:5150 EVANS RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-3606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5881 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3036
Practice Address - Country:US
Practice Address - Phone:440-946-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03233285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist