Provider Demographics
NPI:1205294147
Name:TRUTT, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:TRUTT
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 1:9627 ROUTE 35 STE 20
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:17853-8409
Mailing Address - Country:US
Mailing Address - Phone:570-539-2050
Mailing Address - Fax:
Practice Address - Street 1:9627 ROUTE 35 STE 20
Practice Address - Street 2:
Practice Address - City:MT PLEASANT MILLS
Practice Address - State:PA
Practice Address - Zip Code:17853-8409
Practice Address - Country:US
Practice Address - Phone:570-539-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-07
Last Update Date:2016-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP441800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist