Provider Demographics
NPI:1073657326
Name:PEACOCK, RICHARD MAYNARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MAYNARD
Last Name:PEACOCK
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 1:1856 MILLBANK ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-2671
Mailing Address - Country:US
Mailing Address - Phone:616-243-4979
Mailing Address - Fax:
Practice Address - Street 1:4443 BRETON RD SE
Practice Address - Street 2:SUITE A
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-8424
Practice Address - Country:US
Practice Address - Phone:616-281-3519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist