Provider Demographics
NPI:1104500685
Name:LEWIS, DYLLAN (REGISTERED PHARMACIS)
Entity type:Individual
Prefix:
First Name:DYLLAN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:REGISTERED PHARMACIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 WORKMAN LN
Mailing Address - Street 2:
Mailing Address - City:RENICK
Mailing Address - State:WV
Mailing Address - Zip Code:24966-7024
Mailing Address - Country:US
Mailing Address - Phone:304-667-3645
Mailing Address - Fax:
Practice Address - Street 1:198 POCAHONTAS TRL
Practice Address - Street 2:
Practice Address - City:WHITE SULPHUR SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:24986-5025
Practice Address - Country:US
Practice Address - Phone:304-536-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0013727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist