Provider Demographics
NPI:1679842702
Name:TIARKS, RYAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:TIARKS
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 1:418 E STATE ROUTE 54
Mailing Address - Street 2:
Mailing Address - City:ONARGA
Mailing Address - State:IL
Mailing Address - Zip Code:60955-7603
Mailing Address - Country:US
Mailing Address - Phone:815-383-8121
Mailing Address - Fax:
Practice Address - Street 1:220 S CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866-2309
Practice Address - Country:US
Practice Address - Phone:217-892-8415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist