Provider Demographics
NPI:1730462805
Name:MCDANIEL, TIMOTHY R
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:R
Last Name:MCDANIEL
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 1:102 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42330-1538
Mailing Address - Country:US
Mailing Address - Phone:270-754-1545
Mailing Address - Fax:
Practice Address - Street 1:102 W BROAD ST
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:KY
Practice Address - Zip Code:42330-1538
Practice Address - Country:US
Practice Address - Phone:270-754-1545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010722183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist