Provider Demographics
NPI:1639720717
Name:TYLERTOWN PHARMACY LLC
Entity Type:Organization
Organization Name:TYLERTOWN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:SUMRALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:985-848-7972
Mailing Address - Street 1:30259 PURVIS THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-7363
Mailing Address - Country:US
Mailing Address - Phone:985-848-7972
Mailing Address - Fax:985-986-4433
Practice Address - Street 1:201 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2019
Practice Address - Country:US
Practice Address - Phone:601-222-1770
Practice Address - Fax:601-222-1772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy