Provider Demographics
NPI:1033425871
Name:MADDOX, TIMOTHY GLEN (RPH)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:GLEN
Last Name:MADDOX
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 1:798 BEAL PKWY NW
Mailing Address - Street 2:
Mailing Address - City:FT WALTON BCH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-3042
Mailing Address - Country:US
Mailing Address - Phone:850-864-3727
Mailing Address - Fax:850-864-2845
Practice Address - Street 1:798 BEAL PKWY NW
Practice Address - Street 2:
Practice Address - City:FT WALTON BCH
Practice Address - State:FL
Practice Address - Zip Code:32547-3042
Practice Address - Country:US
Practice Address - Phone:850-864-3727
Practice Address - Fax:850-864-2845
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS20060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist