Provider Demographics
NPI:1043724313
Name:TITCHENER, MARK ALVIN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALVIN
Last Name:TITCHENER
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 1:8860 HIMARK LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-1036
Mailing Address - Country:US
Mailing Address - Phone:307-631-6569
Mailing Address - Fax:
Practice Address - Street 1:4700 N 27TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-1190
Practice Address - Country:US
Practice Address - Phone:402-348-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-25
Last Update Date:2017-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13088183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist