Provider Demographics
NPI:1407305675
Name:BOS, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BOS
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 1:2207 PORTER ST SW # CONDO108
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-2276
Mailing Address - Country:US
Mailing Address - Phone:616-261-4170
Mailing Address - Fax:616-929-4482
Practice Address - Street 1:2207 PORTER ST SW # CONDO108
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-2276
Practice Address - Country:US
Practice Address - Phone:616-261-4170
Practice Address - Fax:616-929-4482
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist