Healthcare Provider Details

I. General information

NPI: 1104500685
Provider Name (Legal Business Name): DYLLAN LEWIS REGISTERED PHARMACIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 13
RONCEVERTE WV
24970-0013
US

IV. Provider business mailing address

361 WORKMAN LN
RENICK WV
24966-7024
US

V. Phone/Fax

Practice location:
  • Phone: 304-667-3645
  • Fax:
Mailing address:
  • Phone: 304-667-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0013727
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: