Provider Demographics
NPI:1235734088
Name:TICKLE, TAMERA M (RPH)
Entity Type:Individual
Prefix:
First Name:TAMERA
Middle Name:M
Last Name:TICKLE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3427
Mailing Address - Country:US
Mailing Address - Phone:540-989-6633
Mailing Address - Fax:540-989-5539
Practice Address - Street 1:4400 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3427
Practice Address - Country:US
Practice Address - Phone:540-989-6633
Practice Address - Fax:540-989-5594
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011826183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist