Provider Demographics
NPI:1730479924
Name:STUCKART, TIM (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIM
Middle Name:
Last Name:STUCKART
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 1:107 E GREENVILLE ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5514
Mailing Address - Country:US
Mailing Address - Phone:864-964-1606
Mailing Address - Fax:
Practice Address - Street 1:107 E GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5514
Practice Address - Country:US
Practice Address - Phone:864-964-1606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC010460183500000X
GA016351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist