Provider Demographics
NPI:1841771995
Name:RILEY, TAILOR ILISE (PHARMD)
Entity Type:Individual
Prefix:
First Name:TAILOR
Middle Name:ILISE
Last Name:RILEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 ALLEN MARCANTEL RD
Mailing Address - Street 2:
Mailing Address - City:KINDER
Mailing Address - State:LA
Mailing Address - Zip Code:70648-5438
Mailing Address - Country:US
Mailing Address - Phone:337-496-5451
Mailing Address - Fax:
Practice Address - Street 1:2010 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5206
Practice Address - Country:US
Practice Address - Phone:337-990-4902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.0225061835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPST.022506OtherLOUISIANA BOARD OF PHARMACY
LAMA.003770OtherLOUISIANA BOARD OF PHARMACY