Provider Demographics
NPI:1174623110
Name:BLACKFORD, TIMOTHY JOHN (RPH)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:BLACKFORD
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 1:2534 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-5918
Mailing Address - Country:US
Mailing Address - Phone:515-279-6307
Mailing Address - Fax:
Practice Address - Street 1:3600 30TH ST
Practice Address - Street 2:VA HOSPITAL
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310
Practice Address - Country:US
Practice Address - Phone:800-294-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist