Provider Demographics
NPI:1396098877
Name:LANG, TYSON BRAD (RPH)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:BRAD
Last Name:LANG
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 1:36363 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:WI
Mailing Address - Zip Code:54773-9186
Mailing Address - Country:US
Mailing Address - Phone:715-538-4947
Mailing Address - Fax:715-538-4598
Practice Address - Street 1:36363 MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:WI
Practice Address - Zip Code:54773-9186
Practice Address - Country:US
Practice Address - Phone:715-538-4947
Practice Address - Fax:715-538-4598
Is Sole Proprietor?:No
Enumeration Date:2012-10-20
Last Update Date:2012-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12531-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist