Provider Demographics
NPI:1730588708
Name:LIGHTSEY, CHAD
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:LIGHTSEY
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 1:401 W FORT WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-2435
Mailing Address - Country:US
Mailing Address - Phone:256-207-2007
Mailing Address - Fax:
Practice Address - Street 1:401 W FORT WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2435
Practice Address - Country:US
Practice Address - Phone:256-207-2007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL113273183500000X
FL50223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL110480Medicaid
AL6417330001Medicare NSC