Provider Demographics
NPI:1902982853
Name:STULTZ, TIMOTHY DALE (BS)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:DALE
Last Name:STULTZ
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 UNDERWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:AINSWORTH
Mailing Address - State:IA
Mailing Address - Zip Code:52201
Mailing Address - Country:US
Mailing Address - Phone:319-530-6309
Mailing Address - Fax:
Practice Address - Street 1:601 HIGHWAY 6 W
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-2292
Practice Address - Country:US
Practice Address - Phone:319-338-0581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist