Provider Demographics
NPI:1063848091
Name:TYSOE, MARIANNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:TYSOE
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:PO BOX 1056
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552-1056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2125 W US HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:THATCHER
Practice Address - State:AZ
Practice Address - Zip Code:85552-5446
Practice Address - Country:US
Practice Address - Phone:928-428-7244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist