Provider Demographics
NPI:1912342098
Name:LYLES, JACOB KENNETH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:KENNETH
Last Name:LYLES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 MEADOWHILL LN
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:KY
Mailing Address - Zip Code:42376-9069
Mailing Address - Country:US
Mailing Address - Phone:615-389-3062
Mailing Address - Fax:
Practice Address - Street 1:440 HOPKINSVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1124
Practice Address - Country:US
Practice Address - Phone:270-338-8406
Practice Address - Fax:270-338-8407
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40170183500000X
ALS10624390200000X
KY018837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program