Provider Demographics
NPI:1396114179
Name:TILLISON, KELLY (PHARM D)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:TILLISON
Suffix:
Gender:F
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 1:207 BERRYWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4209
Mailing Address - Country:US
Mailing Address - Phone:985-259-9657
Mailing Address - Fax:
Practice Address - Street 1:2800 GAUSE BLVD E STE F
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4247
Practice Address - Country:US
Practice Address - Phone:985-641-4252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist