Provider Demographics
NPI:1790097962
Name:LYALL, MATT (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:
Last Name:LYALL
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2714
Mailing Address - Country:US
Mailing Address - Phone:423-547-2733
Mailing Address - Fax:
Practice Address - Street 1:214 BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2714
Practice Address - Country:US
Practice Address - Phone:423-547-2733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-05
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12208183500000X
VA0202205743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist