Provider Demographics
NPI:1568130680
Name:JOHNSON, TYLER AUSTIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:AUSTIN
Last Name:JOHNSON
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 1:1012 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2616
Mailing Address - Country:US
Mailing Address - Phone:918-617-4163
Mailing Address - Fax:
Practice Address - Street 1:2900 SW 134TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5403
Practice Address - Country:US
Practice Address - Phone:405-300-6446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19332183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist