Provider Demographics
NPI:1295330413
Name:BERNAL, TIMOTHY JOHN
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:BERNAL
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 1:3910 HARDY ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1500
Mailing Address - Country:US
Mailing Address - Phone:601-264-6300
Mailing Address - Fax:
Practice Address - Street 1:3910 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1500
Practice Address - Country:US
Practice Address - Phone:601-264-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20303183500000X
MSE-11897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty