Provider Demographics
NPI:1497275267
Name:TYSOR, MISTY DAWN (RPH)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:TYSOR
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:EVA
Mailing Address - State:AL
Mailing Address - Zip Code:35621-8703
Mailing Address - Country:US
Mailing Address - Phone:256-343-1731
Mailing Address - Fax:
Practice Address - Street 1:11610 MEMORIAL PKWY SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35803-2152
Practice Address - Country:US
Practice Address - Phone:256-880-7261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16148183500000X
AL13855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL13855OtherALABAMA BOARD OF PHARMACY