Provider Demographics
NPI:1447711932
Name:LYON, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:LYON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-4160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1235 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1429
Practice Address - Country:US
Practice Address - Phone:662-342-5757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-09081183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE-09081OtherMISSISSIPPI STATE BOARD OF PHARMACY