Provider Demographics
NPI:1942257720
Name:LYON DRUG STORE, INC.
Entity Type:Organization
Organization Name:LYON DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-388-2236
Mailing Address - Street 1:201 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDDYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42038-7752
Mailing Address - Country:US
Mailing Address - Phone:270-388-2236
Mailing Address - Fax:270-388-0900
Practice Address - Street 1:201 MAIN ST
Practice Address - Street 2:
Practice Address - City:EDDYVILLE
Practice Address - State:KY
Practice Address - Zip Code:42038-7752
Practice Address - Country:US
Practice Address - Phone:270-388-2236
Practice Address - Fax:270-388-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP00293332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801958OtherNABP #
KY90040726Medicaid
KY54032735Medicaid
0516560001Medicare NSC