Provider Demographics
NPI:1104122209
Name:LILLISTON, TANYA PHILLIPS (RPH)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:PHILLIPS
Last Name:LILLISTON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:23337 SCHOOL STREET
Mailing Address - City:ACCOMAC
Mailing Address - State:VA
Mailing Address - Zip Code:23301-0817
Mailing Address - Country:US
Mailing Address - Phone:757-710-8534
Mailing Address - Fax:
Practice Address - Street 1:23337 SCHOOL STREET
Practice Address - Street 2:
Practice Address - City:ACCOMAC
Practice Address - State:VA
Practice Address - Zip Code:23301-0817
Practice Address - Country:US
Practice Address - Phone:757-710-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist