MEDICARE: DR. MAXINE CARISSA HILLERY PHARM D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P1200X	Pharmacotherapy Pharmacist	RPH020858	GA

General Provider Information

NPI Number	:	1598853624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAXINE CARISSA HILLERY PHARM D

Provider Business Mailing Address
First Line	:	2402 VININGS OAKS CT SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30082-4610
Country	:	US
Telephone Number	:	770-432-8528
Fax Number	:

Provider Business Practice Location Address
First Line	:	5670 PEACHTREE DUNWOODY RD NE STE 810
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-4717
Country	:	US
Telephone Number	:	404-851-6311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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