Provider Demographics
NPI:1922603547
Name:KNUDSON, TYLER J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:J
Last Name:KNUDSON
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 1:4100 GRAVOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3520
Mailing Address - Country:US
Mailing Address - Phone:314-762-0752
Mailing Address - Fax:
Practice Address - Street 1:4100 GRAVOIS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-3520
Practice Address - Country:US
Practice Address - Phone:314-762-0752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013026479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist