Healthcare Provider Details

I. General information

NPI: 1033425871
Provider Name (Legal Business Name): TIMOTHY GLEN MADDOX RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

798 BEAL PKWY NW
FT WALTON BCH FL
32547-3042
US

IV. Provider business mailing address

798 BEAL PKWY NW
FT WALTON BCH FL
32547-3042
US

V. Phone/Fax

Practice location:
  • Phone: 850-864-3727
  • Fax: 850-864-2845
Mailing address:
  • Phone: 850-864-3727
  • Fax: 850-864-2845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS20060
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: