Healthcare Provider Details

I. General information

NPI: 1154985133
Provider Name (Legal Business Name): TYLER DEL MAXWELL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 05/10/2023
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 CLARKSON AVE # ALL1-519
BROOKLYN NY
11203-2012
US

IV. Provider business mailing address

1510 CARROLL ST APT 3C
BROOKLYN NY
11213-4529
US

V. Phone/Fax

Practice location:
  • Phone: 718-270-4098
  • Fax:
Mailing address:
  • Phone: 209-261-4668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1835I0206X
TaxonomyInfectious Diseases Pharmacist
License Number066123
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: