Provider Demographics
NPI:1104493741
Name:LYDON, MICHAEL J
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:LYDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133-1001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 W LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3425
Practice Address - Country:US
Practice Address - Phone:215-425-3784
Practice Address - Fax:215-425-0740
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP455619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARPI014955OtherPENNSYLVANIA STATE BOARD OF PHARMACY
PARP455619OtherPENNSYLVANIA STATE BOARD OF PHARMACY