Provider Demographics
NPI:1710075635
Name:SWENSEN, TY W (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:W
Last Name:SWENSEN
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 1:965 OCTOBER CV
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-5069
Mailing Address - Country:US
Mailing Address - Phone:208-357-5205
Mailing Address - Fax:
Practice Address - Street 1:965 OCTOBER CV
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-5069
Practice Address - Country:US
Practice Address - Phone:208-357-5205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5187183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist