Provider Demographics
NPI:1720358930
Name:KAUTZMAN, TIM CHARLES (RP)
Entity Type:Individual
Prefix:MR
First Name:TIM
Middle Name:CHARLES
Last Name:KAUTZMAN
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5062 S 155TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-5002
Mailing Address - Country:US
Mailing Address - Phone:402-861-6966
Mailing Address - Fax:402-861-6938
Practice Address - Street 1:5062 S 155TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-5002
Practice Address - Country:US
Practice Address - Phone:402-861-6966
Practice Address - Fax:402-861-6938
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8173183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist