Provider Demographics
NPI:1912304049
Name:LYON, JARED K (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:K
Last Name:LYON
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3160 E 17TH ST STE 164
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6784
Mailing Address - Country:US
Mailing Address - Phone:208-529-1795
Mailing Address - Fax:208-529-1838
Practice Address - Street 1:3160 E 17TH ST STE 164
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6784
Practice Address - Country:US
Practice Address - Phone:208-529-1795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60514388183500000X
UT9321235183500000X
IDP7115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist