Provider Demographics
NPI:1427692425
Name:FREDERICK, TYLER ANTHONY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:ANTHONY
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5202 EAGLES PEAK WAY APT 204
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1389
Mailing Address - Country:US
Mailing Address - Phone:502-744-0099
Mailing Address - Fax:
Practice Address - Street 1:102 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:KY
Practice Address - Zip Code:41095-9300
Practice Address - Country:US
Practice Address - Phone:859-567-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY020737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY020737OtherKENTUCKY BOARD OF PHARMACY
KYF11-171-186OtherKENTUCKY DRIVER'S LICENSE