Provider Demographics
NPI:1194317289
Name:ROSE CITY PHARMACY LLC
Entity type:Organization
Organization Name:ROSE CITY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:L
Authorized Official - Last Name:KREZDORN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:903-707-2034
Mailing Address - Street 1:2130 W GRANDE BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0563
Mailing Address - Country:US
Mailing Address - Phone:903-707-2034
Mailing Address - Fax:903-707-2036
Practice Address - Street 1:2130 W GRANDE BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0563
Practice Address - Country:US
Practice Address - Phone:903-707-2034
Practice Address - Fax:903-707-2036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149679Medicaid