Provider Demographics
NPI:1023227139
Name:TYSON, RONNIE DARRELL (PHARMD)
Entity type:Individual
Prefix:
First Name:RONNIE
Middle Name:DARRELL
Last Name:TYSON
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 1:198 COULTER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-8534
Mailing Address - Country:US
Mailing Address - Phone:803-874-2160
Mailing Address - Fax:
Practice Address - Street 1:198 COULTER RD
Practice Address - Street 2:
Practice Address - City:SAINT MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-8534
Practice Address - Country:US
Practice Address - Phone:803-874-2160
Practice Address - Fax:
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
SC8506183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist