Healthcare Provider Details

I. General information

NPI: 1194486290
Provider Name (Legal Business Name): LYCORX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2022
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 W 3RD ST
WILLIAMSPORT PA
17701-6523
US

IV. Provider business mailing address

200 FIRST RESPONDERS WAY
HAMILTON NJ
08691-1904
US

V. Phone/Fax

Practice location:
  • Phone: 570-429-3505
  • Fax: 570-429-3506
Mailing address:
  • Phone: 609-606-7000
  • Fax: 609-228-6107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: ANN MARIE TAKACS
Title or Position: RPH
Credential:
Phone: 908-458-8710