Provider Demographics
NPI:1659507580
Name:WALLER, TIMOTHY JOSEPH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:WALLER
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 1:2108 EDITH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-0711
Mailing Address - Country:US
Mailing Address - Phone:916-482-6373
Mailing Address - Fax:916-726-5442
Practice Address - Street 1:6661 AUBURN BLVD
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-4925
Practice Address - Country:US
Practice Address - Phone:916-726-1415
Practice Address - Fax:916-726-5442
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29332183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist