Provider Demographics
NPI:1609151240
Name:BLANCK, TIMOTHY JAMES (PHARMD)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:BLANCK
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 1:5542 ASHLEIGH WALK DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7690
Mailing Address - Country:US
Mailing Address - Phone:770-905-8877
Mailing Address - Fax:
Practice Address - Street 1:3980 VENTURE DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5077
Practice Address - Country:US
Practice Address - Phone:770-905-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0247031835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist