Provider Demographics
NPI:1083926273
Name:RICHARD, JUSTIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:RICHARD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 RUSSELL AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2949
Mailing Address - Country:US
Mailing Address - Phone:952-240-8003
Mailing Address - Fax:
Practice Address - Street 1:5415 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1717
Practice Address - Country:US
Practice Address - Phone:612-824-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-05
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118841183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist