Provider Demographics
NPI:1740974534
Name:TYLER, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:TYLER
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 1:729 50TH AVE
Mailing Address - Street 2:
Mailing Address - City:SWEET HOME
Mailing Address - State:OR
Mailing Address - Zip Code:97386-3209
Mailing Address - Country:US
Mailing Address - Phone:541-248-1559
Mailing Address - Fax:
Practice Address - Street 1:913 GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6523
Practice Address - Country:US
Practice Address - Phone:541-440-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0020228183500000X
ORPI-0013933390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program