Provider Demographics
NPI:1497910707
Name:TILLMAN, ROBERT LOUIS
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LOUIS
Last Name:TILLMAN
Suffix:
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 1:4522 CLARENCE AVE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-3110
Mailing Address - Country:US
Mailing Address - Phone:314-389-8616
Mailing Address - Fax:314-381-0157
Practice Address - Street 1:915 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician