Provider Demographics
NPI:1598295396
Name:TIMAKOV, WADIM (PHARMD)
Entity Type:Individual
Prefix:
First Name:WADIM
Middle Name:
Last Name:TIMAKOV
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 WHITE LOAF RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01073-9550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:78 WHITE LOAF RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01073-9550
Practice Address - Country:US
Practice Address - Phone:860-377-7613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0009785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPCT.0009785OtherPHARMACIST LICENSE