MEDICARE: LYNN BUTCHER WILSON P.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PD07527	AR

General Provider Information

NPI Number	:	1538264502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNN BUTCHER WILSON P.D.

Provider Business Mailing Address
First Line	:	908 W 4TH ST
Second Line	:
City	:	FORDYCE
State	:	AR
Zip	:	71742-2216
Country	:	US
Telephone Number	:	870-352-2161
Fax Number	:	870-352-3236

Provider Business Practice Location Address
First Line	:	908 W 4TH ST
Second Line	:
City	:	FORDYCE
State	:	AR
Zip	:	71742-2216
Country	:	US
Telephone Number	:	870-352-2161
Fax Number	:	870-352-3236

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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