Healthcare Provider Details

I. General information

NPI: 1326643313
Provider Name (Legal Business Name): TYLER KENNEDY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 S ATHERTON ST
STATE COLLEGE PA
16801-6209
US

IV. Provider business mailing address

1630 S ATHERTON ST
STATE COLLEGE PA
16801-6209
US

V. Phone/Fax

Practice location:
  • Phone: 814-237-1479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP451294
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: