Healthcare Provider Details

I. General information

NPI: 1619645637
Provider Name (Legal Business Name): CARLY ANN TYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 09/03/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 CLYDE PARK AVE SW
WYOMING MI
49509-4023
US

IV. Provider business mailing address

500 COIT AVE NE APT 302
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-257-6641
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302413669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: