Provider Demographics
NPI:1487208823
Name:TYLER, REGAN NICOLE
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:NICOLE
Last Name:TYLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 LAKELAND DR APT 470
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4630
Mailing Address - Country:US
Mailing Address - Phone:901-413-8179
Mailing Address - Fax:
Practice Address - Street 1:1497 CANTON MART RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5435
Practice Address - Country:US
Practice Address - Phone:601-956-2421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-16022183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist