Provider Demographics
NPI:1659974624
Name:LYN, LEIVAUGHN
Entity Type:Individual
Prefix:
First Name:LEIVAUGHN
Middle Name:
Last Name:LYN
Suffix:
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 1:9197 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3405
Mailing Address - Country:US
Mailing Address - Phone:772-335-4668
Mailing Address - Fax:
Practice Address - Street 1:9197 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3405
Practice Address - Country:US
Practice Address - Phone:772-335-4668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL617541835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist