Provider Demographics
NPI:1790844462
Name:LEWIS, LON WALLDA (RPH)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:WALLDA
Last Name:LEWIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 MERION
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2414
Mailing Address - Country:US
Mailing Address - Phone:912-638-8585
Mailing Address - Fax:912-264-1392
Practice Address - Street 1:5711 ALTAMA AVE
Practice Address - Street 2:SUITE J
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-2240
Practice Address - Country:US
Practice Address - Phone:912-264-2622
Practice Address - Fax:912-264-1392
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH010977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist