=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639770019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER CERUTTI PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2020
-----------------------------------------------------
Last Update Date | 11/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1307 HIGHWAY K
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63366-5978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-980-9300
-----------------------------------------------------
Fax | 636-978-8447
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 854 HIGHWAY 47 E APT F
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63379-6341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 2020027158
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------