Provider Demographics
NPI:1972876449
Name:TYSON, CATHERINE ELAINE (PHARM D)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:ELAINE
Last Name:TYSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 DALLAS ROAD
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180
Mailing Address - Country:US
Mailing Address - Phone:770-456-3152
Mailing Address - Fax:770-456-3200
Practice Address - Street 1:601 DALLAS ROAD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180
Practice Address - Country:US
Practice Address - Phone:770-456-3152
Practice Address - Fax:770-456-3200
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist