=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164536314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TILLEY APOTHECARIES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 12/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11411 BROOKSHIRE AVE SUITE #107
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90241-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-923-1256
-----------------------------------------------------
Fax | 562-923-1847
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11411 BROOKSHIRE AVE SUITE #107
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90241-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-923-1256
-----------------------------------------------------
Fax | 562-923-1847
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JOHN E. TILLEY
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 562-862-8416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY30655
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------