Provider Demographics
NPI:1144826165
Name:FEARON, TYSON RICHARD
Entity type:Individual
Prefix:DR
First Name:TYSON
Middle Name:RICHARD
Last Name:FEARON
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 1:532 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1526
Mailing Address - Country:US
Mailing Address - Phone:207-282-4131
Mailing Address - Fax:
Practice Address - Street 1:532 MAIN ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1526
Practice Address - Country:US
Practice Address - Phone:207-282-4131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist