Provider Demographics
NPI:1316549801
Name:CARLYLE, DEBORA ANN
Entity Type:Individual
Prefix:
First Name:DEBORA
Middle Name:ANN
Last Name:CARLYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 TRAILSIDE BND
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-2115
Mailing Address - Country:US
Mailing Address - Phone:512-587-4560
Mailing Address - Fax:
Practice Address - Street 1:3701 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-4975
Practice Address - Country:US
Practice Address - Phone:512-352-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28169183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist