Provider Demographics
NPI:1043261084
Name:TULLY, TAMMY T (OD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:T
Last Name:TULLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 50997
Mailing Address - Street 2:4606 MOONBEAM CT
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0017
Mailing Address - Country:US
Mailing Address - Phone:843-520-0576
Mailing Address - Fax:843-520-4398
Practice Address - Street 1:109 FINNEGAN CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4205
Practice Address - Country:US
Practice Address - Phone:843-903-0949
Practice Address - Fax:843-903-1101
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1061152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9681Medicaid
SCU5336Medicare UPIN