Provider Demographics
NPI:1063474450
Name:RICHARDSON, LARRY G (DPH)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:G
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:MR
Other - First Name:RICK
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPH
Mailing Address - Street 1:1415 COURTLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401
Mailing Address - Country:US
Mailing Address - Phone:931-381-0348
Mailing Address - Fax:931-380-2075
Practice Address - Street 1:425 WEST 7TH STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401
Practice Address - Country:US
Practice Address - Phone:931-388-3232
Practice Address - Fax:931-380-2075
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC1320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist