Provider Demographics
NPI:1760533343
Name:TILLER, KEVIN WADE (RPH)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:WADE
Last Name:TILLER
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 1:424 DICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-2601
Mailing Address - Country:US
Mailing Address - Phone:210-364-8566
Mailing Address - Fax:
Practice Address - Street 1:2450 STANLEY RD STE 208
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-6102
Practice Address - Country:US
Practice Address - Phone:210-221-8681
Practice Address - Fax:210-295-2789
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015237183500000X
TX44097183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist