Provider Demographics
NPI:1629472618
Name:PRUSSMAN, LYLE JR (PHARMD)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:
Last Name:PRUSSMAN
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-3357
Mailing Address - Country:US
Mailing Address - Phone:507-433-7447
Mailing Address - Fax:
Practice Address - Street 1:905 N MAIN ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-3357
Practice Address - Country:US
Practice Address - Phone:507-433-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist