Provider Demographics
NPI:1942070693
Name:BURNS, TYLER PHILLIP
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:PHILLIP
Last Name:BURNS
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 1:1830 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:FL
Mailing Address - Zip Code:32619-4713
Mailing Address - Country:US
Mailing Address - Phone:352-463-0400
Mailing Address - Fax:
Practice Address - Street 1:1830 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:FL
Practice Address - Zip Code:32619-4713
Practice Address - Country:US
Practice Address - Phone:352-463-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist