Healthcare Provider Details

I. General information

NPI: 1225479819
Provider Name (Legal Business Name): WYLIE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 S HIGHWAY 78 STE 160
WYLIE TX
75098-3974
US

IV. Provider business mailing address

430 S HIGHWAY 78 SUITE 160
WYLIE TX
75098-3905
US

V. Phone/Fax

Practice location:
  • Phone: 972-429-9594
  • Fax: 972-429-9482
Mailing address:
  • Phone: 972-429-9594
  • Fax: 972-429-9482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28505
License Number StateTX

VIII. Authorized Official

Name: SRIKRISHNA BOPPANA
Title or Position: PIC
Credential:
Phone: 972-429-9594