Healthcare Provider Details

I. General information

NPI: 1730224361
Provider Name (Legal Business Name): CAREY PROSPERIE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2119 E 5TH ST
TYLER TX
75701-3515
US

IV. Provider business mailing address

2119 E 5TH ST
TYLER TX
75701-3515
US

V. Phone/Fax

Practice location:
  • Phone: 903-597-3383
  • Fax: 903-597-2129
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number13550
License Number StateTX

VIII. Authorized Official

Name: DENA FERMAN
Title or Position: THIRD PARTY PLAN COORDINATOR
Credential:
Phone: 314-993-6000