Healthcare Provider Details

I. General information

NPI: 1508771239
Provider Name (Legal Business Name): TYLER DAVIS PHARMD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 1ST ST
PAYNESVILLE MN
56362-1445
US

IV. Provider business mailing address

13983 HOLLYHOCK LN
ROGERS MN
55374-8878
US

V. Phone/Fax

Practice location:
  • Phone: 320-243-7702
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number127506
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: