Provider Demographics
NPI:1912480864
Name:TYCZ, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:TYCZ
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 1:7 MACKENZIE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-1486
Mailing Address - Country:US
Mailing Address - Phone:774-258-1529
Mailing Address - Fax:508-248-3868
Practice Address - Street 1:7 MACKENZIE DR
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:MA
Practice Address - Zip Code:01507-1486
Practice Address - Country:US
Practice Address - Phone:774-258-1529
Practice Address - Fax:508-248-3868
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH21601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist