Provider Demographics
NPI:1518360189
Name:PINILLA, TARA M
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:M
Last Name:PINILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1876 E BLACKSTOCK RD
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-2700
Mailing Address - Country:US
Mailing Address - Phone:864-574-8323
Mailing Address - Fax:864-574-9147
Practice Address - Street 1:1876 E BLACKSTOCK RD
Practice Address - Street 2:
Practice Address - City:ROEBUCK
Practice Address - State:SC
Practice Address - Zip Code:29376-2700
Practice Address - Country:US
Practice Address - Phone:864-574-8323
Practice Address - Fax:864-574-9147
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist