Provider Demographics
NPI:1083755854
Name:GUSTIN, RICHARD W (RPH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:W
Last Name:GUSTIN
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 1:917 16TH AVENUE CT SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4817
Mailing Address - Country:US
Mailing Address - Phone:253-426-6920
Mailing Address - Fax:253-426-6420
Practice Address - Street 1:1708 SOUTH YAKIMA AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5307
Practice Address - Country:US
Practice Address - Phone:253-426-6920
Practice Address - Fax:253-426-6420
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00008051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist