Healthcare Provider Details

I. General information

NPI: 1891181798
Provider Name (Legal Business Name): DR. MICHAEL LYONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1558 MONTEITH AVE
HERNANDO MS
38632-7685
US

IV. Provider business mailing address

1558 MONTEITH AVE
HERNANDO MS
38632-7685
US

V. Phone/Fax

Practice location:
  • Phone: 662-449-3663
  • Fax: 662-449-3676
Mailing address:
  • Phone: 662-449-3663
  • Fax: 662-449-3676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number14296
License Number StateMS

VIII. Authorized Official

Name: MICHAEL LYONS
Title or Position: OWNER
Credential:
Phone: 662-449-3663