Provider Demographics
NPI:1477648764
Name:MITCHELL, TIMOTHY G (RPH)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:MITCHELL
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 1:15334 HERON DR
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850
Mailing Address - Country:US
Mailing Address - Phone:417-451-9501
Mailing Address - Fax:417-451-9594
Practice Address - Street 1:1000 S NEOSHO BLVD
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850
Practice Address - Country:US
Practice Address - Phone:417-451-9501
Practice Address - Fax:417-451-9594
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist