Provider Demographics
NPI:1205385739
Name:TRISDALE, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:TRISDALE
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 1:1940 GAINESBORO HWY
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:TN
Mailing Address - Zip Code:38544-3706
Mailing Address - Country:US
Mailing Address - Phone:931-239-5381
Mailing Address - Fax:
Practice Address - Street 1:14978 RANKIN AVE
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:TN
Practice Address - Zip Code:37327-7006
Practice Address - Country:US
Practice Address - Phone:423-949-4049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist