Provider Demographics
NPI:1851976351
Name:TITA, LIONEL BUMA
Entity Type:Individual
Prefix:
First Name:LIONEL
Middle Name:BUMA
Last Name:TITA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 AMBROSE AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-2028
Mailing Address - Country:US
Mailing Address - Phone:713-498-7149
Mailing Address - Fax:
Practice Address - Street 1:5976 OLD JACKSONVILLE HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0582
Practice Address - Country:US
Practice Address - Phone:903-405-6215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68297183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX34126033OtherDRIVER'S LICENSE