Provider Demographics
NPI:1134296585
Name:SOUTH LYON MEDICAL CENTER PHARMACY
Entity Type:Organization
Organization Name:SOUTH LYON MEDICAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:A
Authorized Official - Last Name:INSERRA
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:775-463-6404
Mailing Address - Street 1:PO BOX 940
Mailing Address - Street 2:
Mailing Address - City:YERINGTON
Mailing Address - State:NV
Mailing Address - Zip Code:89447-0940
Mailing Address - Country:US
Mailing Address - Phone:775-463-2301
Mailing Address - Fax:
Practice Address - Street 1:213 S WHITACRE ST
Practice Address - Street 2:
Practice Address - City:YERINGTON
Practice Address - State:NV
Practice Address - Zip Code:89447-2561
Practice Address - Country:US
Practice Address - Phone:775-463-2301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVIB007883336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002810863Medicaid