Provider Demographics
NPI:1164597696
Name:TILL, LEWIS TRAYWICK JR
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:TRAYWICK
Last Name:TILL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 FARMSTEAD LN
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-9731
Mailing Address - Country:US
Mailing Address - Phone:803-707-4164
Mailing Address - Fax:
Practice Address - Street 1:165 FARMSTEAD LN
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-9731
Practice Address - Country:US
Practice Address - Phone:803-707-4164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist