Healthcare Provider Details

I. General information

NPI: 1861562944
Provider Name (Legal Business Name): TYLER DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N MAIN ST
WETUMKA OK
74883-3028
US

IV. Provider business mailing address

105 N MAIN ST
WETUMKA OK
74883-3028
US

V. Phone/Fax

Practice location:
  • Phone: 405-452-3203
  • Fax: 405-452-3352
Mailing address:
  • Phone: 405-452-3203
  • Fax: 405-452-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number40-3422
License Number StateOK

VIII. Authorized Official

Name: HOWARD TYLER
Title or Position: GENERAL PARTNER
Credential: RPH
Phone: 405-452-3203