Provider Demographics
NPI:1679610554
Name:MALMO, TIMOTHY ERIC (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ERIC
Last Name:MALMO
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 1:15579 CHERRY PATH
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-2586
Mailing Address - Country:US
Mailing Address - Phone:651-322-7351
Mailing Address - Fax:
Practice Address - Street 1:1399 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-2427
Practice Address - Country:US
Practice Address - Phone:651-437-9608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114670183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist