Provider Demographics
NPI:1558369850
Name:GILLIAM, CHERYL DIANE (RPH)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:DIANE
Last Name:GILLIAM
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 1:1900 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75602-3212
Mailing Address - Country:US
Mailing Address - Phone:903-758-8286
Mailing Address - Fax:903-758-2728
Practice Address - Street 1:1900 S HIGH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75602-3212
Practice Address - Country:US
Practice Address - Phone:903-758-8286
Practice Address - Fax:903-758-2728
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist