Provider Demographics
NPI:1427524529
Name:ANCONA, TYLER JAMES
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:JAMES
Last Name:ANCONA
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 1:1000 AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-6744
Mailing Address - Country:US
Mailing Address - Phone:864-247-8882
Mailing Address - Fax:
Practice Address - Street 1:1118 MACK ST
Practice Address - Street 2:
Practice Address - City:GASTON
Practice Address - State:SC
Practice Address - Zip Code:29053-8713
Practice Address - Country:US
Practice Address - Phone:706-778-4918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37806183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist