Provider Demographics
NPI:1902597404
Name:TYSHCHYSHYN, DMYTRO I
Entity Type:Individual
Prefix:
First Name:DMYTRO
Middle Name:I
Last Name:TYSHCHYSHYN
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 1:2414 CRESCENT WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3585
Mailing Address - Country:US
Mailing Address - Phone:980-425-4118
Mailing Address - Fax:
Practice Address - Street 1:9026 SEMINOLE TRL
Practice Address - Street 2:
Practice Address - City:RUCKERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22968-3319
Practice Address - Country:US
Practice Address - Phone:434-985-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist