Provider Demographics
NPI:1316390008
Name:LICHLYTER, TIMOTHY L (RPH)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:LICHLYTER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 CRATER LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9753
Mailing Address - Country:US
Mailing Address - Phone:541-690-1130
Mailing Address - Fax:
Practice Address - Street 1:2924 SISKIYOU BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8194
Practice Address - Country:US
Practice Address - Phone:541-773-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00069531835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist