Provider Demographics
NPI:1679542161
Name:GALLEGOS, TIMOTHY J (RPH)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:J
Last Name:GALLEGOS
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 1:4631 DICKERSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RANSOMVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14131-9752
Mailing Address - Country:US
Mailing Address - Phone:716-754-8186
Mailing Address - Fax:
Practice Address - Street 1:302 S TRANSIT ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-4851
Practice Address - Country:US
Practice Address - Phone:716-433-3733
Practice Address - Fax:716-433-3720
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35898-1183500000X
NMRP-00004045183500000X
UT143808-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01981488Medicaid