Provider Demographics
NPI:1679553325
Name:LYON DRUG STORE INC
Entity Type:Organization
Organization Name:LYON DRUG STORE INC
Other - Org Name:MCCONNELL HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-388-2236
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:KUTTAWA
Mailing Address - State:KY
Mailing Address - Zip Code:42055-0459
Mailing Address - Country:US
Mailing Address - Phone:270-388-7371
Mailing Address - Fax:270-388-5675
Practice Address - Street 1:86 CEDAR ST
Practice Address - Street 2:
Practice Address - City:KUTTAWA
Practice Address - State:KY
Practice Address - Zip Code:42055-0159
Practice Address - Country:US
Practice Address - Phone:270-388-7371
Practice Address - Fax:270-388-5675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP077173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100376080Medicaid
2154564OtherPK
KY54005699Medicaid