Provider Demographics
NPI:1881476075
Name:LACEY, TIMOTHY LEE (BS PD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LEE
Last Name:LACEY
Suffix:
Gender:M
Credentials:BS PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 E CARMICHAEL RD
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-9609
Mailing Address - Country:US
Mailing Address - Phone:501-231-1130
Mailing Address - Fax:
Practice Address - Street 1:518 CLAY ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-6024
Practice Address - Country:US
Practice Address - Phone:501-217-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD070303336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy