Healthcare Provider Details

I. General information

NPI: 1407563315
Provider Name (Legal Business Name): LATOYA JODIAN LYTTLE-FORRESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 S MILTON RD
FLAGSTAFF AZ
86001-0802
US

IV. Provider business mailing address

1650 S MILTON RD
FLAGSTAFF AZ
86001-0802
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-2661
  • Fax:
Mailing address:
  • Phone: 928-779-2661
  • Fax: 928-864-5608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS026078
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: