Provider Demographics
NPI:1467003657
Name:MAIN, TYLER RAY (PHARMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:RAY
Last Name:MAIN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 S HIGHWAY 97
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-9647
Mailing Address - Country:US
Mailing Address - Phone:541-504-4166
Mailing Address - Fax:
Practice Address - Street 1:1705 S HIGHWAY 97
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-9647
Practice Address - Country:US
Practice Address - Phone:541-504-4166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0017504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist