Healthcare Provider Details

I. General information

NPI: 1639651250
Provider Name (Legal Business Name): TYLER WILLIAM LIEBEGOTT PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PROSPECT ST
JAMESTOWN NY
14701-6609
US

IV. Provider business mailing address

10 PROSPECT ST
JAMESTOWN NY
14701-6609
US

V. Phone/Fax

Practice location:
  • Phone: 716-661-9230
  • Fax: 716-661-9226
Mailing address:
  • Phone: 166-611-9230
  • Fax: 716-661-9226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP452566
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number069811
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: