Provider Demographics
NPI:1225479819
Name:WYLIE PHARMACY LLC
Entity Type:Organization
Organization Name:WYLIE PHARMACY LLC
Other - Org Name:WYLIE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:SRIKRISHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOPPANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-429-9594
Mailing Address - Street 1:430 S HIGHWAY 78
Mailing Address - Street 2:SUITE 160
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-3905
Mailing Address - Country:US
Mailing Address - Phone:972-429-9594
Mailing Address - Fax:972-429-9482
Practice Address - Street 1:430 S HIGHWAY 78 STE 160
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-3974
Practice Address - Country:US
Practice Address - Phone:972-429-9594
Practice Address - Fax:972-429-9482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-11
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX285053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141040OtherPK
TX146807Medicaid