Provider Demographics
NPI:1710323712
Name:BROWN, TIMOTHY DONALD (PHARMD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DONALD
Last Name:BROWN
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:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:ID
Mailing Address - Zip Code:83355-0487
Mailing Address - Country:US
Mailing Address - Phone:208-536-5761
Mailing Address - Fax:208-536-5852
Practice Address - Street 1:280 S IDAHO ST
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:ID
Practice Address - Zip Code:83355-5200
Practice Address - Country:US
Practice Address - Phone:208-536-5761
Practice Address - Fax:208-536-5852
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5751183500000X, 1835N0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N0905XPharmacy Service ProvidersPharmacistNuclear
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP5751OtherSTATE LICENSE NUMBER