Provider Demographics
NPI:1639427990
Name:DANIELS, LYSETTE (PHARMD RPH)
Entity Type:Individual
Prefix:DR
First Name:LYSETTE
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:PHARMD RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:SMITHS GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42171-7292
Mailing Address - Country:US
Mailing Address - Phone:270-597-2345
Mailing Address - Fax:
Practice Address - Street 1:110 BAILEY RD
Practice Address - Street 2:
Practice Address - City:SMITHS GROVE
Practice Address - State:KY
Practice Address - Zip Code:42171-7292
Practice Address - Country:US
Practice Address - Phone:270-780-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist