Provider Demographics
NPI:1871217786
Name:RAVENER, TYLER
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:RAVENER
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 1:4761 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4761 SUNRISE HIGHWAY
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716
Practice Address - Country:US
Practice Address - Phone:631-567-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist