Provider Demographics
NPI:1265473748
Name:YANTIS, TIMOTHY L (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:L
Last Name:YANTIS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 CHETCO AVENUE
Mailing Address - Street 2:P. O. 547
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415
Mailing Address - Country:US
Mailing Address - Phone:541-469-2616
Mailing Address - Fax:541-412-0744
Practice Address - Street 1:890 CHETCO AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-469-2616
Practice Address - Fax:541-412-0744
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH00006858183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR033357Medicaid
OR3801126OtherNCPDP
OR3801126OtherNCPDP