Provider Demographics
NPI:1447536859
Name:TILLMAN, PAUL RUSSELL
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RUSSELL
Last Name:TILLMAN
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 1:3414 MUNDY MILL RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30507-8215
Mailing Address - Country:US
Mailing Address - Phone:770-287-8359
Mailing Address - Fax:770-287-8606
Practice Address - Street 1:3414 MUNDY MILL RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30507-8215
Practice Address - Country:US
Practice Address - Phone:770-287-8359
Practice Address - Fax:770-287-8606
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-30
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022817183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist