Healthcare Provider Details

I. General information

NPI: 1508784018
Provider Name (Legal Business Name): JADAH SIMONE LYONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W CALIFORNIA AVE
RUSTON LA
71270-5014
US

IV. Provider business mailing address

555 CONCORDIA PARK DR
VIDALIA LA
71373-3732
US

V. Phone/Fax

Practice location:
  • Phone: 318-255-1811
  • Fax:
Mailing address:
  • Phone: 601-870-3183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPST.026292
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: