Provider Demographics
NPI:1336742873
Name:MYERS, TRISTAN
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:MYERS
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 1:2001 S THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6329
Mailing Address - Country:US
Mailing Address - Phone:479-927-1568
Mailing Address - Fax:479-927-1879
Practice Address - Street 1:2001 S THOMPSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6329
Practice Address - Country:US
Practice Address - Phone:479-927-1568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12820183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist