Provider Demographics
NPI:1376808170
Name:OSLER, TAVIS JOHN
Entity Type:Individual
Prefix:
First Name:TAVIS
Middle Name:JOHN
Last Name:OSLER
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 1:217 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2651
Mailing Address - Country:US
Mailing Address - Phone:208-765-9586
Mailing Address - Fax:208-765-6922
Practice Address - Street 1:217 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2651
Practice Address - Country:US
Practice Address - Phone:208-765-9586
Practice Address - Fax:208-765-6922
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-08
Last Update Date:2012-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5650183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist