Provider Demographics
NPI:1013005057
Name:TYSON, LAURA EUGENA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:EUGENA
Last Name:TYSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31639-1426
Mailing Address - Country:US
Mailing Address - Phone:229-316-8200
Mailing Address - Fax:229-686-2687
Practice Address - Street 1:501 N DAVIS ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:GA
Practice Address - Zip Code:31639-1426
Practice Address - Country:US
Practice Address - Phone:229-316-8200
Practice Address - Fax:229-686-2687
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA016946OtherSTATE PHARMACIST LICENSE