Provider Demographics
NPI:1922375054
Name:LYDICK, MARK (PHARM D)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LYDICK
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 1:11119 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3203
Mailing Address - Country:US
Mailing Address - Phone:804-744-5986
Mailing Address - Fax:804-744-6156
Practice Address - Street 1:11119 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3203
Practice Address - Country:US
Practice Address - Phone:804-744-5986
Practice Address - Fax:804-744-6156
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202012297183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist