Healthcare Provider Details

I. General information

NPI: 1083745509
Provider Name (Legal Business Name): TIMBERLAKE HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22776 TIMBERLAKE RD APT D
LYNCHBURG VA
24502-7310
US

IV. Provider business mailing address

22776 TIMBERLAKE RD APT D
LYNCHBURG VA
24502-7310
US

V. Phone/Fax

Practice location:
  • Phone: 434-237-6337
  • Fax: 434-237-6338
Mailing address:
  • Phone: 434-237-6337
  • Fax: 434-237-6338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0201004144
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number0201004144
License Number StateVA

VIII. Authorized Official

Name: JODI V. ETTARE
Title or Position: SUPERVISING PHARMACIST
Credential: R.PH.
Phone: 434-237-6337