Provider Demographics
NPI:1568739241
Name:TYSINGER, BOBBY
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:TYSINGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3437 WHITAKER RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27011-9225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:722 W INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3574
Practice Address - Country:US
Practice Address - Phone:336-789-9006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist