Provider Demographics
NPI:1487284014
Name:TILLERY, ERIKA VANCE (PHARMD)
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:VANCE
Last Name:TILLERY
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 1:730 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-2358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2358
Practice Address - Country:US
Practice Address - Phone:770-749-5095
Practice Address - Fax:770-749-0228
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0292351835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH029235OtherGEORGIA BOARD OF PHARMACY