Healthcare Provider Details

I. General information

NPI: 1659656361
Provider Name (Legal Business Name): WILLIAM STEPHEN TULLOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 STILL CT
MADISONVILLE LA
70447-3303
US

IV. Provider business mailing address

811 STILL CT
MADISONVILLE LA
70447-3303
US

V. Phone/Fax

Practice location:
  • Phone: 985-626-8106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16336
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: