Provider Demographics
NPI:1902569486
Name:TILAHUN, SURAPHAEL S
Entity Type:Individual
Prefix:
First Name:SURAPHAEL
Middle Name:S
Last Name:TILAHUN
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 1:668 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-7416
Mailing Address - Country:US
Mailing Address - Phone:706-595-1667
Mailing Address - Fax:
Practice Address - Street 1:668 MAIN ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-7416
Practice Address - Country:US
Practice Address - Phone:706-595-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist