MEDICARE: DR. BRADLEY CLEVELAND TYRE 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	183500000X	Pharmacist	018632	GA

General Provider Information

NPI Number	:	1770612335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY CLEVELAND TYRE PHARM D.

Provider Business Mailing Address
First Line	:	529 CLEMENT CIR
Second Line	:
City	:	ST SIMONS ISLAND
State	:	GA
Zip	:	31522-5805
Country	:	US
Telephone Number	:	912-634-7309
Fax Number	:

Provider Business Practice Location Address
First Line	:	2927 DEMERE RD
Second Line	:
City	:	ST SIMONS ISLAND
State	:	GA
Zip	:	31522-1620
Country	:	US
Telephone Number	:	912-638-1999
Fax Number	:	912-638-2112

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/08/2007

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