Provider Demographics
NPI:1942365614
Name:LYDDANE, JASON WILLIAM (RPH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:WILLIAM
Last Name:LYDDANE
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 1:1 SAINT JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3742
Mailing Address - Country:US
Mailing Address - Phone:859-313-1723
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3742
Practice Address - Country:US
Practice Address - Phone:859-313-1723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist