Provider Demographics
NPI:1508096777
Name:TILLERY, KIM E (RPH)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:E
Last Name:TILLERY
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 1:2638 LONGBOW DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-8946
Mailing Address - Country:US
Mailing Address - Phone:208-735-4076
Mailing Address - Fax:208-324-4599
Practice Address - Street 1:2638 LONGBOW DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-8946
Practice Address - Country:US
Practice Address - Phone:208-735-4076
Practice Address - Fax:208-324-4599
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP45851835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist