Healthcare Provider Details

I. General information

NPI: 1376774927
Provider Name (Legal Business Name): TIM LYON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N UNION ST
OLEAN NY
14760-2617
US

IV. Provider business mailing address

1 CVS DR
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 716-372-5881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number053624
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: