Provider Demographics
NPI:1225142219
Name:SOUTHLAND LEGEND PHARMACY
Entity Type:Organization
Organization Name:SOUTHLAND LEGEND PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:BENEDETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-534-8218
Mailing Address - Street 1:5201 S BROADWAY AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5201 S BROADWAY AVE
Practice Address - Street 2:STE 100
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3748
Practice Address - Country:US
Practice Address - Phone:903-534-8218
Practice Address - Fax:903-534-2897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17039333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144423Medicaid
4572093OtherOTHER ID NUMBER-COMMERCIAL NUMBER