Provider Demographics
NPI:1700075835
Name:KOCH, TIMOTHY ROBERT (RPH)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:KOCH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716
Mailing Address - Country:US
Mailing Address - Phone:479-204-8627
Mailing Address - Fax:479-273-8675
Practice Address - Street 1:702 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72716-6209
Practice Address - Country:US
Practice Address - Phone:479-204-8627
Practice Address - Fax:479-273-8675
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist