Provider Demographics
NPI:1609158898
Name:TILLEY, KEITH (RPH)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:TILLEY
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 1:1427 N HARRISON
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801
Mailing Address - Country:US
Mailing Address - Phone:405-390-8741
Mailing Address - Fax:405-273-0542
Practice Address - Street 1:1427 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-5245
Practice Address - Country:US
Practice Address - Phone:405-273-8520
Practice Address - Fax:405-273-0542
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist