Provider Demographics
NPI:1174743876
Name:RICHARDSON, TIMOTHY MICHAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:RICHARDSON
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 1:5404 N NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-2209
Mailing Address - Country:US
Mailing Address - Phone:773-631-6651
Mailing Address - Fax:
Practice Address - Street 1:101 W VALLETTE ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-4419
Practice Address - Country:US
Practice Address - Phone:630-834-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist