Provider Demographics
NPI:1710091418
Name:MIODEK, TIMOTHY J
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:J
Last Name:MIODEK
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 1:12853 CORBIN DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-3311
Mailing Address - Country:US
Mailing Address - Phone:586-254-9551
Mailing Address - Fax:
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:SUITE 124
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1116
Practice Address - Country:US
Practice Address - Phone:586-447-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030353183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist