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General NPI Number Information
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NPI Number | 1225479819
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Entity Type | Organization
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Legal Business Name | WYLIE PHARMACY LLC
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Dates
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Enumeration Date | 07/11/2013
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Last Update Date | 01/14/2014
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Provider Practice Location Address
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Address Line | 430 S HIGHWAY 78 STE 160
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City | WYLIE
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State | TX
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Zip | 75098-3974
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Country | US
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Telephone | 972-429-9594
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Fax | 972-429-9482
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Provider Business Mailing Address
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Address Line | 430 S HIGHWAY 78 SUITE 160
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City | WYLIE
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State | TX
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Zip | 75098-3905
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Country | US
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Telephone | 972-429-9594
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Fax | 972-429-9482
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Authorized Official
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Title or Position | PIC
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Name | SRIKRISHNA BOPPANA
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Credential |
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Telephone | 972-429-9594
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 28505
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License Number State | TX
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