Provider Demographics
NPI:1902557622
Name:TYREE, AUSTIN
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:TYREE
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 1:323 S WALKER ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:323 S WALKER ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2756
Practice Address - Country:US
Practice Address - Phone:304-431-4967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0012729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRP0012729OtherPHARMACIST