Healthcare Provider Details

I. General information

NPI: 1326323775
Provider Name (Legal Business Name): RYAN F LYTLE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10580 W USTICK RD
BOISE ID
83704-5267
US

IV. Provider business mailing address

13501 W WITTENBURG ST
BOISE ID
83713-0842
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-3581
  • Fax:
Mailing address:
  • Phone: 208-938-2091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP6435
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: