Provider Demographics
NPI:1043642317
Name:TILLEY, KIMBERLY JOANNA (PHARM D)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:JOANNA
Last Name:TILLEY
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 1:357750 E 5200 RD
Mailing Address - Street 2:
Mailing Address - City:MARAMEC
Mailing Address - State:OK
Mailing Address - Zip Code:74045-1010
Mailing Address - Country:US
Mailing Address - Phone:918-519-7960
Mailing Address - Fax:
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637-1548
Practice Address - Country:US
Practice Address - Phone:918-519-7960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK150361835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist