Provider Demographics
NPI:1306128087
Name:MATTHEWS, TIMOTHY J JR
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:MATTHEWS
Suffix:JR
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 1:4621 ROOKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-3438
Mailing Address - Country:US
Mailing Address - Phone:563-940-1590
Mailing Address - Fax:
Practice Address - Street 1:3455 MANN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-2337
Practice Address - Country:US
Practice Address - Phone:317-487-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024287A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist