Provider Demographics
NPI:1578897658
Name:TILLIS, NATHAN (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:TILLIS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 HENLEY RD
Mailing Address - Street 2:WINN DIXIE
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-7204
Mailing Address - Country:US
Mailing Address - Phone:904-899-6902
Mailing Address - Fax:904-291-3288
Practice Address - Street 1:2851 HENLEY RD
Practice Address - Street 2:WINN DIXIE
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-7204
Practice Address - Country:US
Practice Address - Phone:904-899-6902
Practice Address - Fax:904-291-3288
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2013-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34236183500000X
GARPH020986183500000X
WAPH00053534183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist