Healthcare Provider Details

I. General information

NPI: 1679553325
Provider Name (Legal Business Name): LYON DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 CEDAR ST
KUTTAWA KY
42055-0159
US

IV. Provider business mailing address

PO BOX 459
KUTTAWA KY
42055-0459
US

V. Phone/Fax

Practice location:
  • Phone: 270-388-7371
  • Fax: 270-388-5675
Mailing address:
  • Phone: 270-388-7371
  • Fax: 270-388-5675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP07717
License Number StateKY

VIII. Authorized Official

Name: EDWIN NICKELL
Title or Position: PRESIDENT
Credential:
Phone: 270-388-2236