Healthcare Provider Details

I. General information

NPI: 1346851425
Provider Name (Legal Business Name): TYLER KENNEDY PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 2ND AVE N
PARK FALLS WI
54552-1299
US

IV. Provider business mailing address

N15588 WAGNER RD
PARK FALLS WI
54552-8259
US

V. Phone/Fax

Practice location:
  • Phone: 715-762-3283
  • Fax:
Mailing address:
  • Phone: 715-661-3262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19551-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: