Provider Demographics
NPI:1962884544
Name:TYAN PHARMACY & MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:TYAN PHARMACY & MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:215-639-9400
Mailing Address - Street 1:2803 BRISTOL PIKE
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-5362
Mailing Address - Country:US
Mailing Address - Phone:215-639-9400
Mailing Address - Fax:215-639-9401
Practice Address - Street 1:2803 BRISTOL PIKE
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-5362
Practice Address - Country:US
Practice Address - Phone:215-639-9400
Practice Address - Fax:215-639-9401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336S0011X
PAPP4825603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030274210001Medicaid