Provider Demographics
NPI:1639373921
Name:LYONS, MARY JO JO (RPH)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:JO
Last Name:LYONS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8394 N PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8253
Mailing Address - Country:US
Mailing Address - Phone:208-762-9100
Mailing Address - Fax:208-772-7905
Practice Address - Street 1:161 W PRAIRIE SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9853
Practice Address - Country:US
Practice Address - Phone:208-772-7864
Practice Address - Fax:208-772-7905
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5213183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist