Provider Demographics
NPI:1346463114
Name:CONDON, TIMOTHY ALLEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:CONDON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S EMERALD DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3964
Mailing Address - Country:US
Mailing Address - Phone:715-845-8462
Mailing Address - Fax:
Practice Address - Street 1:1105 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ROTHSCHILD
Practice Address - State:WI
Practice Address - Zip Code:54474-1024
Practice Address - Country:US
Practice Address - Phone:715-359-3146
Practice Address - Fax:715-359-0145
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9322040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist