Provider Demographics
NPI:1174251730
Name:TIELL, CARLA SUE
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:SUE
Last Name:TIELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13235 SUMNER ST
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:OH
Mailing Address - Zip Code:43569-9647
Mailing Address - Country:US
Mailing Address - Phone:419-601-8964
Mailing Address - Fax:
Practice Address - Street 1:722-740 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402
Practice Address - Country:US
Practice Address - Phone:419-354-3911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician