MEDICARE: MRS. MITZIE ANN LYONS D.PH.

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	9074	OK

General Provider Information

NPI Number	:	1902985294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MITZIE ANN LYONS D.PH.

Provider Business Mailing Address
First Line	:	112 S BROADWAY ST
Second Line	:
City	:	WALTERS
State	:	OK
Zip	:	73572-2033
Country	:	US
Telephone Number	:	580-875-3188
Fax Number	:	580-875-3229

Provider Business Practice Location Address
First Line	:	112 S BROADWAY ST
Second Line	:
City	:	WALTERS
State	:	OK
Zip	:	73572-2033
Country	:	US
Telephone Number	:	580-875-3188
Fax Number	:	580-875-3229

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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