Provider Demographics
NPI:1265501506
Name:RICHARDSON, BOB WANSLEY (RPH)
Entity Type:Individual
Prefix:MR
First Name:BOB
Middle Name:WANSLEY
Last Name:RICHARDSON
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 1:8173 MONTICELLO ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014
Mailing Address - Country:US
Mailing Address - Phone:770-787-3478
Mailing Address - Fax:770-786-2285
Practice Address - Street 1:4104 TATE ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014
Practice Address - Country:US
Practice Address - Phone:770-786-2284
Practice Address - Fax:770-786-2285
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist