Provider Demographics
NPI:1033788740
Name:LAETSCH, TYLER J (PHARMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:LAETSCH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 S CLIFF AVE STE CP
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1008
Mailing Address - Country:US
Mailing Address - Phone:402-340-4357
Mailing Address - Fax:
Practice Address - Street 1:1325 S CLIFF AVE STE CP
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1008
Practice Address - Country:US
Practice Address - Phone:402-340-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR-6549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty