Provider Demographics
NPI:1902885288
Name:THOMPSON, TIMOTHY TIMELL SR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:TIMELL
Last Name:THOMPSON
Suffix:SR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SHADY LANE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-4308
Mailing Address - Country:US
Mailing Address - Phone:901-219-8000
Mailing Address - Fax:228-822-5783
Practice Address - Street 1:5502 MARVIN SHIELDS BLVD.
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-822-5783
Practice Address - Fax:228-871-3648
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204745183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202204745OtherLISCENSE NUMBER