Provider Demographics
NPI:1881565935
Name:MILLICAN, LANAM JACK
Entity type:Individual
Prefix:
First Name:LANAM
Middle Name:JACK
Last Name:MILLICAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 APPLEWOOD DR APT C
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-2713
Mailing Address - Country:US
Mailing Address - Phone:806-240-3707
Mailing Address - Fax:
Practice Address - Street 1:4700 E PALM VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-2580
Practice Address - Country:US
Practice Address - Phone:512-218-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist