Provider Demographics
NPI:1285964197
Name:LILL, DOUGLAS DEAN (RPH, CCN)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DEAN
Last Name:LILL
Suffix:
Gender:M
Credentials:RPH, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 RANDOLPH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-5940
Mailing Address - Country:US
Mailing Address - Phone:512-426-2894
Mailing Address - Fax:
Practice Address - Street 1:430 RANDOLPH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5940
Practice Address - Country:US
Practice Address - Phone:512-426-2894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH000006551835N1003X
TX307111835N1003X
NJ29RI032405001835N1003X
MD193421835N1003X
PARP4426221835N1003X
NY053358-11835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support