Healthcare Provider Details

I. General information

NPI: 1659892081
Provider Name (Legal Business Name): MATTHEW JOHN LYTLE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S CLOVERDALE BLVD
CLOVERDALE CA
95425-4413
US

IV. Provider business mailing address

1301 PRENTICE DR APT 7
HEALDSBURG CA
95448-3388
US

V. Phone/Fax

Practice location:
  • Phone: 707-894-5206
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number75816
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: