Healthcare Provider Details

I. General information

NPI: 1851028252
Provider Name (Legal Business Name): TYLER KEDIS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4930 BLUE DIAMOND RD
LAS VEGAS NV
89139-7604
US

IV. Provider business mailing address

45 MALEENA MESA ST APT 1622
HENDERSON NV
89074-8145
US

V. Phone/Fax

Practice location:
  • Phone: 702-260-9695
  • Fax:
Mailing address:
  • Phone: 562-708-9156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23015
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: