Provider Demographics
NPI:1558472548
Name:BRYSON, WILLIAM LUTHER (PH)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:LUTHER
Last Name:BRYSON
Suffix:
Gender:M
Credentials:PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75426-3160
Mailing Address - Country:US
Mailing Address - Phone:903-427-2805
Mailing Address - Fax:903-427-4291
Practice Address - Street 1:131 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-3160
Practice Address - Country:US
Practice Address - Phone:903-427-2805
Practice Address - Fax:903-427-4291
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20004183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144948Medicaid