Provider Demographics
NPI:1912508003
Name:MATTOCKS, TYLER O (PHARMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:O
Last Name:MATTOCKS
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 1:4309 HUNTLEIGH CT
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-3928
Mailing Address - Country:US
Mailing Address - Phone:405-706-8508
Mailing Address - Fax:
Practice Address - Street 1:3571 W ROCK CREEK RD
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-2473
Practice Address - Country:US
Practice Address - Phone:405-515-7286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist