MEDICARE: RYAN DOUGLAS TIEDEMAN RPH

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PH00021344	WA

General Provider Information

NPI Number	:	1841400777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN DOUGLAS TIEDEMAN RPH

Provider Business Mailing Address
First Line	:	21602 29TH ST E
Second Line	:
City	:	LAKE TAPPS
State	:	WA
Zip	:	98391-5620
Country	:	US
Telephone Number	:	253-299-6104
Fax Number	:	253-891-7327

Provider Business Practice Location Address
First Line	:	20901 STATE ROUTE 410 E
Second Line	:
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-6302
Country	:	US
Telephone Number	:	253-891-7333
Fax Number	:	253-891-7327

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	05/30/2026

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