Provider Demographics
NPI:1659076420
Name:LYDICK, KELLY ANN (CPHT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:LYDICK
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 OAKDALE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH VERSAILLES
Mailing Address - State:PA
Mailing Address - Zip Code:15137-1903
Mailing Address - Country:US
Mailing Address - Phone:412-378-2071
Mailing Address - Fax:
Practice Address - Street 1:2336 ARDMORE BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15221-5202
Practice Address - Country:US
Practice Address - Phone:412-273-3487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
22011020352331183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician