Provider Demographics
NPI:1144381880
Name:WILLIAM L BRYSON INC
Entity Type:Organization
Organization Name:WILLIAM L BRYSON INC
Other - Org Name:BLACKMON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LUTHER
Authorized Official - Last Name:BRYSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-427-2805
Mailing Address - Street 1:131 N LOCUST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75426-3160
Mailing Address - Country:US
Mailing Address - Phone:903-427-2805
Mailing Address - Fax:903-427-4291
Practice Address - Street 1:131 N LOCUST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-3160
Practice Address - Country:US
Practice Address - Phone:903-427-2805
Practice Address - Fax:903-427-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2004183500000X
TX200043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144948Medicaid