Provider Demographics
NPI:1992851786
Name:ANTONELLI, TIMOTHY JOHN (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:ANTONELLI
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 1:600 EAST LAFAYETTE BLVD
Mailing Address - Street 2:MAIL CODE 512C
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-2998
Mailing Address - Country:US
Mailing Address - Phone:313-448-7372
Mailing Address - Fax:
Practice Address - Street 1:600 E LAFAYETTE BLVD
Practice Address - Street 2:MAIL CODE 512C
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2998
Practice Address - Country:US
Practice Address - Phone:248-448-7372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist