Healthcare Provider Details

I. General information

NPI: 1902985294
Provider Name (Legal Business Name): MITZIE ANN LYONS D.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S BROADWAY ST
WALTERS OK
73572-2033
US

IV. Provider business mailing address

112 S BROADWAY ST
WALTERS OK
73572-2033
US

V. Phone/Fax

Practice location:
  • Phone: 580-875-3188
  • Fax: 580-875-3229
Mailing address:
  • Phone: 580-875-3188
  • Fax: 580-875-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9074
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: