Healthcare Provider Details

I. General information

NPI: 1497867006
Provider Name (Legal Business Name): LORI LYNNE KIDDY RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MAIN ST
LONACONING MD
21539-1122
US

IV. Provider business mailing address

935 PINECREST DR C-3
CUMBERLAND MD
21502-1942
US

V. Phone/Fax

Practice location:
  • Phone: 301-463-5757
  • Fax:
Mailing address:
  • Phone: 301-268-1606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10773
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: