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General NPI Number Information
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NPI Number | 1205385739
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Entity Type | Individual
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Provider Name | TYLER TRISDALE
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Gender | Male
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Dates
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Enumeration Date | 09/26/2016
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Last Update Date | 09/26/2016
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Provider Practice Location Address
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Address Line | 14978 RANKIN AVE
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City | DUNLAP
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State | TN
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Zip | 37327-7006
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Country | US
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Telephone | 423-949-4049
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Fax |
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Provider Business Mailing Address
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Address Line | 1940 GAINESBORO HWY
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City | BAXTER
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State | TN
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Zip | 38544-3706
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Country | US
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Telephone | 931-239-5381
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 40491
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License Number State | TN
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