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General NPI Number Information
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NPI Number | 1427524529
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Entity Type | Individual
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Provider Name | DR. TYLER JAMES ANCONA
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Gender | Male
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Dates
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Enumeration Date | 10/17/2018
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Last Update Date | 10/17/2018
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Provider Practice Location Address
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Address Line | 1118 MACK ST
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City | GASTON
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State | SC
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Zip | 29053-8713
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Country | US
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Telephone | 706-778-4918
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Fax |
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Provider Business Mailing Address
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Address Line | 1000 AUGUSTA ST
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City | WEST COLUMBIA
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State | SC
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Zip | 29169-6744
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Country | US
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Telephone | 864-247-8882
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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 | 37806
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License Number State | SC
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