Provider Demographics
NPI:1316655392
Name:HAYGOOD, BRYAN L (RPH)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:L
Last Name:HAYGOOD
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 1:2321 W LOOP 281
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-2563
Mailing Address - Country:US
Mailing Address - Phone:903-297-0558
Mailing Address - Fax:903-297-7496
Practice Address - Street 1:2321 W LOOP 281
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2563
Practice Address - Country:US
Practice Address - Phone:903-297-0558
Practice Address - Fax:903-297-7496
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27620OtherVACCINE