Provider Demographics
NPI:1619450392
Name:BORMANN, TIMOTHY RICHARD
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:BORMANN
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 1:115 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-2906
Mailing Address - Country:US
Mailing Address - Phone:515-576-5320
Mailing Address - Fax:515-576-4078
Practice Address - Street 1:115 S 29TH ST
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-2906
Practice Address - Country:US
Practice Address - Phone:515-576-5320
Practice Address - Fax:515-576-4078
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist