Healthcare Provider Details

I. General information

NPI: 1275746240
Provider Name (Legal Business Name): TYRUS PARK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94-780A MEHEULA PKWY
MILILANI HI
96789
US

IV. Provider business mailing address

141 N CIVIC DR
WALNUT CREEK CA
94596
US

V. Phone/Fax

Practice location:
  • Phone: 808-623-6636
  • Fax: 808-625-3894
Mailing address:
  • Phone: 925-210-6659
  • Fax: 925-210-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1586
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: