Basic Information
Provider Information | |||||||||
NPI: | 1023115714 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LILLY | ||||||||
FirstName: | RONALD | ||||||||
MiddleName: | LEROY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 BRAGG BLVD | ||||||||
Address2: |   | ||||||||
City: | ODENTON | ||||||||
State: | MD | ||||||||
PostalCode: | 211132629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106742599 | ||||||||
FaxNumber: | 4106057160 | ||||||||
Practice Location | |||||||||
Address1: | 10 N GREENE ST | ||||||||
Address2: | ATTN: PHARMACY SVC (119) | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212011524 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106057000 | ||||||||
FaxNumber: | 4106057160 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 12950 | MD | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.