Provider Demographics
NPI:1326152315
Name:STEPHENSON PHARMACY
Entity Type:Organization
Organization Name:STEPHENSON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEALY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-593-0236
Mailing Address - Street 1:1000 S FLEISHEL AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2037
Mailing Address - Country:US
Mailing Address - Phone:903-593-0236
Mailing Address - Fax:903-593-9375
Practice Address - Street 1:1000 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2037
Practice Address - Country:US
Practice Address - Phone:903-593-0236
Practice Address - Fax:903-593-9375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336C0004X
TX25664333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC08420064Medicaid
TX010403601Medicaid
TX4552027OtherNABP
4552027OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX0802150001Medicare NSC