Healthcare Provider Details

I. General information

NPI: 1124626742
Provider Name (Legal Business Name): TIMOTHY CARTER III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 E DAYTON YELLOW SPRINGS RD
FAIRBORN OH
45324-6325
US

IV. Provider business mailing address

150 TRI COUNTY PKWY
SPRINGDALE OH
45246-3217
US

V. Phone/Fax

Practice location:
  • Phone: 513-318-3920
  • Fax: 513-318-3921
Mailing address:
  • Phone: 513-782-3366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03337164
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: