Healthcare Provider Details

I. General information

NPI: 1093412025
Provider Name (Legal Business Name): TIMOTHY WYATT QUILLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 JAMES E HANNAH DR
SOUTH SHORE KY
41175-9600
US

IV. Provider business mailing address

2216 OHIO RIVER RD
GREENUP KY
41144-6603
US

V. Phone/Fax

Practice location:
  • Phone: 606-932-3614
  • Fax:
Mailing address:
  • Phone: 606-923-9155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number008916
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: