Provider Demographics
NPI:1346851425
Name:KENNEDY, TYLER (PHARM D)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:KENNEDY
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:N15588 WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:PARK FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54552-8259
Mailing Address - Country:US
Mailing Address - Phone:715-661-3262
Mailing Address - Fax:
Practice Address - Street 1:138 2ND AVE N
Practice Address - Street 2:
Practice Address - City:PARK FALLS
Practice Address - State:WI
Practice Address - Zip Code:54552-1299
Practice Address - Country:US
Practice Address - Phone:715-762-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19551-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist