Provider Demographics
NPI:1841400777
Name:TIEDEMAN, RYAN DOUGLAS (RPH)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DOUGLAS
Last Name:TIEDEMAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21602 29TH ST E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-5620
Mailing Address - Country:US
Mailing Address - Phone:253-299-6104
Mailing Address - Fax:253-891-7327
Practice Address - Street 1:20901 STATE ROUTE 410 E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6302
Practice Address - Country:US
Practice Address - Phone:253-891-7333
Practice Address - Fax:253-891-7327
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00021344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist