Provider Demographics
NPI:1760824445
Name:TYLER, MALLORY MICHELLE
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:MICHELLE
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 1:1000 KIRBY RD APT C305
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3085
Mailing Address - Country:US
Mailing Address - Phone:901-626-8791
Mailing Address - Fax:
Practice Address - Street 1:1401 E HARDING AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-6167
Practice Address - Country:US
Practice Address - Phone:870-536-7928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist