=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689774622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY JAMES CUEVAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 HIGHWAY 11 S
-----------------------------------------------------
City | PICAYUNE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39466-5382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-798-4771
-----------------------------------------------------
Fax | 601-798-6130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28180 HIGHWAY 603
-----------------------------------------------------
City | PERKINSTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39573-3791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-255-3828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | E06914
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------