Provider Demographics
NPI:1720453368
Name:HENDERSON, TYSON (PHARMD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:HENDERSON
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 1:7203 S COURSE VW
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHLAND CITY
Practice Address - State:TN
Practice Address - Zip Code:37015-1403
Practice Address - Country:US
Practice Address - Phone:615-729-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000039058183500000X
WAPH00042726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist