Provider Demographics
NPI:1356896104
Name:PERRY, TIANTAYA
Entity type:Individual
Prefix:
First Name:TIANTAYA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 N WYMAN RD
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48888-9538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 E CENTER ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1618
Practice Address - Country:US
Practice Address - Phone:989-875-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist