Healthcare Provider Details

I. General information

NPI: 1902431943
Provider Name (Legal Business Name): JOHNATHON TYLER BYRD PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 W MAIN ST
STEELE MO
63877-1434
US

IV. Provider business mailing address

6860 HIGHWAY 78
DYERSBURG TN
38024-6206
US

V. Phone/Fax

Practice location:
  • Phone: 573-695-4533
  • Fax: 573-695-3327
Mailing address:
  • Phone: 731-676-7107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2019027663
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number42325
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: