Healthcare Provider Details

I. General information

NPI: 1912304049
Provider Name (Legal Business Name): JARED K LYON PHARMD., RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3160 E 17TH ST STE 164
AMMON ID
83406-6784
US

IV. Provider business mailing address

3160 E 17TH ST STE 164
AMMON ID
83406-6784
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-1795
  • Fax:
Mailing address:
  • Phone: 208-529-1795
  • Fax: 208-529-1838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60514388
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9321235
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7115
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: