Provider Demographics
NPI:1497415244
Name:STEVENS, TYLER ALLEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ALLEN
Last Name:STEVENS
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 1:1019 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6188
Mailing Address - Country:US
Mailing Address - Phone:908-809-2412
Mailing Address - Fax:
Practice Address - Street 1:201 1ST STREET SOUTH
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651
Practice Address - Country:US
Practice Address - Phone:208-466-7869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP94621835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP9462Medicaid