Provider Demographics
NPI:1336209410
Name:PIERCE, TIMOTHY SHAWN (RPH, MS)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:SHAWN
Last Name:PIERCE
Suffix:
Gender:M
Credentials:RPH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BRODHEAD DR
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-8710
Mailing Address - Country:US
Mailing Address - Phone:315-699-0273
Mailing Address - Fax:315-676-2902
Practice Address - Street 1:3045 EAST AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-9502
Practice Address - Country:US
Practice Address - Phone:315-676-2944
Practice Address - Fax:315-676-2902
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY020-034227Medicaid