Provider Demographics
NPI:1619645637
Name:TYSON, CARLY ANN
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:TYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 COIT AVE NE
Mailing Address - Street 2:APT 302
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 CLYDE PARK AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4023
Practice Address - Country:US
Practice Address - Phone:616-257-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist