Provider Demographics
NPI:1629685698
Name:CLARK, TYLER TODD
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:TODD
Last Name:CLARK
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 1:325 HOFFMAN DR APT 312
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-3282
Mailing Address - Country:US
Mailing Address - Phone:320-515-1620
Mailing Address - Fax:
Practice Address - Street 1:1130 W FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-5662
Practice Address - Country:US
Practice Address - Phone:507-451-3323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist