Healthcare Provider Details

I. General information

NPI: 1992424998
Provider Name (Legal Business Name): RYAN TYLER MICHAEL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N CHURCH ST
HAZLETON PA
18201-1842
US

IV. Provider business mailing address

PO BOX 622
NUREMBERG PA
18241-0622
US

V. Phone/Fax

Practice location:
  • Phone: 570-450-7272
  • Fax:
Mailing address:
  • Phone: 570-861-2683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP457047
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: