Provider Demographics
NPI:1235561044
Name:RUSIN, TYLER JORDAN I (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:JORDAN
Last Name:RUSIN
Suffix:I
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 1:17825 HALTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-0698
Mailing Address - Country:US
Mailing Address - Phone:304-545-1911
Mailing Address - Fax:
Practice Address - Street 1:17825 HALTON PARK, APT. 3B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262
Practice Address - Country:US
Practice Address - Phone:304-545-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23683183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist