Provider Demographics
NPI:1376111641
Name:LYON, JOHN B III
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:LYON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 RR 12 UNIT 2A
Mailing Address - Street 2:
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-5332
Mailing Address - Country:US
Mailing Address - Phone:512-847-7520
Mailing Address - Fax:512-842-8032
Practice Address - Street 1:14100 RR 12 UNIT 2A
Practice Address - Street 2:
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-5332
Practice Address - Country:US
Practice Address - Phone:512-847-7520
Practice Address - Fax:512-842-8032
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist