Basic Information
Provider Information | |||||||||
NPI: | 1376213355 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUSKINSON | ||||||||
FirstName: | TYSON | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 397 THOMSON FARMS RD UNIT 1306 | ||||||||
Address2: |   | ||||||||
City: | REXBURG | ||||||||
State: | ID | ||||||||
PostalCode: | 834404997 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2089704624 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2325 CORONADO ST | ||||||||
Address2: |   | ||||||||
City: | IDAHO FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 834047407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2085572700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2021 | ||||||||
LastUpdateDate: | 10/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | P9413 | ID | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.