Provider Demographics
NPI:1790392934
Name:TRAN, TYLER TRUNG THANH
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:TRUNG THANH
Last Name:TRAN
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 1:250 CITRUS TOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2790
Mailing Address - Country:US
Mailing Address - Phone:352-241-6676
Mailing Address - Fax:
Practice Address - Street 1:250 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2790
Practice Address - Country:US
Practice Address - Phone:352-241-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist