Healthcare Provider Details

I. General information

NPI: 1831888098
Provider Name (Legal Business Name): TYLER ANN GIPSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TYLER GIPSON FOWLER PHARMD

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MEDICAL CIR STE 106B
ATHENS TX
75751-9004
US

IV. Provider business mailing address

1110 MILL RUN RD
ATHENS TX
75751-3521
US

V. Phone/Fax

Practice location:
  • Phone: 903-877-5067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number64906
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number64906
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number64906
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code1835C0207X
TaxonomyCompounded Sterile Preparations Pharmacist
License Number64906
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: