Provider Demographics
NPI:1972870558
Name:TIMMERMAN, KENNETH JAY (RP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAY
Last Name:TIMMERMAN
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-2734
Mailing Address - Country:US
Mailing Address - Phone:402-435-3271
Mailing Address - Fax:402-474-3425
Practice Address - Street 1:1701 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-2734
Practice Address - Country:US
Practice Address - Phone:402-435-3271
Practice Address - Fax:402-474-3425
Is Sole Proprietor?:No
Enumeration Date:2011-11-26
Last Update Date:2011-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9323183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist