Provider Demographics
NPI:1164705497
Name:SPENCER, TYSON C (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:C
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 W QUINN RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4988
Mailing Address - Country:US
Mailing Address - Phone:208-238-4049
Mailing Address - Fax:208-238-4046
Practice Address - Street 1:305 W QUINN RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4988
Practice Address - Country:US
Practice Address - Phone:208-238-4049
Practice Address - Fax:208-238-4046
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6120183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist