Provider Demographics
NPI:1477505618
Name:SS TYLER LP
Entity Type:Organization
Organization Name:SS TYLER LP
Other - Org Name:QVL PHARMACY 102
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-624-3050
Mailing Address - Street 1:PO BOX 803493
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75380-3493
Mailing Address - Country:US
Mailing Address - Phone:214-624-3073
Mailing Address - Fax:214-989-7986
Practice Address - Street 1:1321 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-3323
Practice Address - Country:US
Practice Address - Phone:903-593-1706
Practice Address - Fax:903-593-5513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX239093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2097627OtherPK
TX145570Medicaid