Provider Demographics
NPI:1093487225
Name:MCINTOSH, TYLER G
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:G
Last Name:MCINTOSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-5434
Mailing Address - Country:US
Mailing Address - Phone:620-228-4184
Mailing Address - Fax:
Practice Address - Street 1:401 W FRONTIER LN
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-7225
Practice Address - Country:US
Practice Address - Phone:913-294-9125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-100901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist