Provider Demographics
NPI:1366069171
Name:WINDSOR, TIMOTHY LANCE (RPH)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LANCE
Last Name:WINDSOR
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 1:1206 W CAYMAN CV
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-4303
Mailing Address - Country:US
Mailing Address - Phone:309-264-4553
Mailing Address - Fax:
Practice Address - Street 1:4814 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5928
Practice Address - Country:US
Practice Address - Phone:309-688-6752
Practice Address - Fax:309-688-7106
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-037770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist