Provider Demographics
NPI:1619203478
Name:CAMPBELL, TYLER G (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:G
Last Name:CAMPBELL
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 1:1700 CERRILLOS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3554
Mailing Address - Country:US
Mailing Address - Phone:505-946-9379
Mailing Address - Fax:
Practice Address - Street 1:1700 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3554
Practice Address - Country:US
Practice Address - Phone:505-946-9379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRPH.03129401-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist