Provider Demographics
NPI:1598770737
Name:OURSBOURN, TIMOTHY S (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:S
Last Name:OURSBOURN
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 1:504 AVENUE Q
Mailing Address - Street 2:
Mailing Address - City:SHALLOWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79363-6407
Mailing Address - Country:US
Mailing Address - Phone:806-928-0609
Mailing Address - Fax:
Practice Address - Street 1:3402 SLIDE RD
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-2542
Practice Address - Country:US
Practice Address - Phone:806-797-8840
Practice Address - Fax:806-797-1851
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMRP00007099OtherNEW MEXICO STATE BOARD OF PHARMACY
TX39024OtherSTATE LICENSE