Provider Demographics
NPI:1356965115
Name:BLACK, TYLER (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:BLACK
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 1:47-388 HUI IWA ST
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-4428
Mailing Address - Country:US
Mailing Address - Phone:808-239-3204
Mailing Address - Fax:
Practice Address - Street 1:47-388 HUI IWA ST
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-4428
Practice Address - Country:US
Practice Address - Phone:808-239-3204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-07
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist