Provider Demographics
NPI:1750702270
Name:TILLEY, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:TILLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11411 BROOKSHIRE AVE
Mailing Address - Street 2:SUITE #107
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-5026
Mailing Address - Country:US
Mailing Address - Phone:562-923-1256
Mailing Address - Fax:562-923-1847
Practice Address - Street 1:11411 BROOKSHIRE AVE
Practice Address - Street 2:SUITE #107
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-5026
Practice Address - Country:US
Practice Address - Phone:562-923-1256
Practice Address - Fax:562-923-1847
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH31351183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy