Basic Information
| Provider Information | |||||||||
| NPI: | 1780982983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 EUBANKS | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744648807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184581006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | RT 6 | ||||||||
| Address2: | 840 | ||||||||
| City: | STILWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186968800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2011 | ||||||||
| LastUpdateDate: | 03/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 11619 | OK | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.