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General NPI Number Information
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NPI Number | 1679842702
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Entity Type | Individual
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Provider Name | RYAN TIARKS PHARMD
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Gender | Male
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Dates
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Enumeration Date | 12/19/2011
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Last Update Date | 12/19/2011
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Provider Practice Location Address
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Address Line | 220 S CENTURY BLVD
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City | RANTOUL
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State | IL
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Zip | 61866-2309
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Country | US
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Telephone | 217-892-8415
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Fax |
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Provider Business Mailing Address
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Address Line | 418 E STATE ROUTE 54
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City | ONARGA
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State | IL
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Zip | 60955-7603
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Country | US
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Telephone | 815-383-8121
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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 | 051.293611
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License Number State | IL
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