MEDICARE: TECIA RYAN, PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835N1003X	Nutrition Support Pharmacist	27261	CA
2	1835P1200X	Pharmacotherapy Pharmacist	27261	CA

General Provider Information

NPI Number	:	1750543302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TECIA RYAN, PHARM.D.

Provider Business Mailing Address
First Line	:	2515 MILVIA ST
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94704-2605
Country	:	US
Telephone Number	:	510-385-5094
Fax Number	:	510-981-1678

Provider Business Practice Location Address
First Line	:	2515 MILVIA ST
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94704-2605
Country	:	US
Telephone Number	:	510-385-5094
Fax Number	:	510-981-1678

Authorized Official
Title or Position	:	CEO, CFO, SOLE STOCKHOLDER
Name	:	DR. TECIA GAIL RYAN
Credential	:	PHARM.D.
Telephone Number	:	510-385-5094

Provider Enumeration Date	:	06/25/2008
Last Update Date	:	06/25/2008

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