Provider Demographics
NPI:1841754314
Name:TULLIS, MATT (RPH)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:TULLIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 ARGO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-5113
Mailing Address - Country:US
Mailing Address - Phone:210-289-2151
Mailing Address - Fax:
Practice Address - Street 1:8812 BROADWAY ST STE A
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-6318
Practice Address - Country:US
Practice Address - Phone:210-624-7648
Practice Address - Fax:888-217-1216
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist