Provider Demographics
NPI:1285270504
Name:BASSAGOU, TYIKA (RPH)
Entity type:Individual
Prefix:DR
First Name:TYIKA
Middle Name:
Last Name:BASSAGOU
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CROYDON CT APT 1
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4112
Mailing Address - Country:US
Mailing Address - Phone:240-601-3883
Mailing Address - Fax:
Practice Address - Street 1:1815 CONN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-5702
Practice Address - Country:US
Practice Address - Phone:202-332-1718
Practice Address - Fax:202-332-9033
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26943183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist