Provider Demographics
NPI:1255381265
Name:TYFAN INC.
Entity type:Organization
Organization Name:TYFAN INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:BS - NURSING
Authorized Official - Phone:276-796-2200
Mailing Address - Street 1:PO BOX 1480
Mailing Address - Street 2:
Mailing Address - City:POUND
Mailing Address - State:VA
Mailing Address - Zip Code:24279-1480
Mailing Address - Country:US
Mailing Address - Phone:276-796-2200
Mailing Address - Fax:276-796-2202
Practice Address - Street 1:11231 INDIAN CREEK ROAD
Practice Address - Street 2:
Practice Address - City:POUND
Practice Address - State:VA
Practice Address - Zip Code:24279
Practice Address - Country:US
Practice Address - Phone:276-796-2200
Practice Address - Fax:276-796-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010040803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100266980Medicaid
VA010266238Medicaid
2105920OtherPK
VA010266238Medicaid