Provider Demographics
NPI:1982878260
Name:TILLAPAUGH, WILLIAM WALTER
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:WALTER
Last Name:TILLAPAUGH
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 1:3857 STATE ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1309
Mailing Address - Country:US
Mailing Address - Phone:315-652-5190
Mailing Address - Fax:315-652-5190
Practice Address - Street 1:3857 STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-1309
Practice Address - Country:US
Practice Address - Phone:315-652-5190
Practice Address - Fax:315-652-5190
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02348103Medicaid