Provider Demographics
NPI:1255312823
Name:TYNER PHARMACY INC
Entity Type:Organization
Organization Name:TYNER PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-853-4342
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:WENONA
Mailing Address - State:IL
Mailing Address - Zip Code:61377-0601
Mailing Address - Country:US
Mailing Address - Phone:815-853-4342
Mailing Address - Fax:815-853-4342
Practice Address - Street 1:120 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WENONA
Practice Address - State:IL
Practice Address - Zip Code:61377-7527
Practice Address - Country:US
Practice Address - Phone:815-853-4342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid