MEDICARE: TYLER JAMES CLOVER PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051304105	IL

General Provider Information

NPI Number	:	1144994583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER JAMES CLOVER PHARMD

Provider Business Mailing Address
First Line	:	625 LINCOLN HWY
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2121
Country	:	US
Telephone Number	:	618-624-4313
Fax Number	:

Provider Business Practice Location Address
First Line	:	625 LINCOLN HWY
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2121
Country	:	US
Telephone Number	:	618-624-4313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2021
Last Update Date	:	08/08/2021

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