Provider Demographics
NPI:1477606325
Name:CORPORATE HEALTH DIMENSIONS DBA GOODYEAR PHARMACY TYLER
Entity type:Organization
Organization Name:CORPORATE HEALTH DIMENSIONS DBA GOODYEAR PHARMACY TYLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DELANA
Authorized Official - Middle Name:D
Authorized Official - Last Name:STATEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-592-3487
Mailing Address - Street 1:P. O. BOX 5450
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712
Mailing Address - Country:US
Mailing Address - Phone:903-592-3487
Mailing Address - Fax:903-593-8737
Practice Address - Street 1:13221 FM 206 HWY 31 W
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75709
Practice Address - Country:US
Practice Address - Phone:903-592-3487
Practice Address - Fax:903-593-8737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15096183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty