Provider Demographics
NPI:1255562930
Name:TIPTON, JASON RILEY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:RILEY
Last Name:TIPTON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 MIDLAN DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-6316
Mailing Address - Country:US
Mailing Address - Phone:217-257-1332
Mailing Address - Fax:
Practice Address - Street 1:3700 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-2822
Practice Address - Country:US
Practice Address - Phone:217-224-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist