Provider Demographics
NPI:1144629924
Name:GITTENS, TYMON ELLIOTT
Entity type:Individual
Prefix:DR
First Name:TYMON
Middle Name:ELLIOTT
Last Name:GITTENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S EXETER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4316
Mailing Address - Country:US
Mailing Address - Phone:410-962-6520
Mailing Address - Fax:410-637-4731
Practice Address - Street 1:630 S EXETER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4316
Practice Address - Country:US
Practice Address - Phone:410-962-6520
Practice Address - Fax:410-637-4731
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist