Provider Demographics
NPI:1023614278
Name:COLGROVE, TIMOTHY KEITH (PHARMD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:KEITH
Last Name:COLGROVE
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 1:4215 AZURITE ST
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-0653
Mailing Address - Country:US
Mailing Address - Phone:404-775-6426
Mailing Address - Fax:
Practice Address - Street 1:21 N CAROLINA ST
Practice Address - Street 2:
Practice Address - City:HARTWELL
Practice Address - State:GA
Practice Address - Zip Code:30643-7206
Practice Address - Country:US
Practice Address - Phone:706-376-3147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist