Provider Demographics
NPI:1467567099
Name:MALLETT, TIMOTHY JOHN (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:MALLETT
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 1:7404 W H AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-8586
Mailing Address - Country:US
Mailing Address - Phone:269-372-8233
Mailing Address - Fax:269-375-9662
Practice Address - Street 1:117 W PATERSON ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-2557
Practice Address - Country:US
Practice Address - Phone:269-488-0835
Practice Address - Fax:269-349-2685
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist