Provider Demographics
NPI:1508375841
Name:CLEMONS, TYLER (PHARMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:CLEMONS
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 1:2720 S HIGHLAND AVE APT 572
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-7152
Mailing Address - Country:US
Mailing Address - Phone:920-540-8677
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:920-540-8677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.300787183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist