Provider Demographics
NPI:1275710642
Name:FATTIC, RICHARD LAUREL
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LAUREL
Last Name:FATTIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 W. 19TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46209-0291
Mailing Address - Country:US
Mailing Address - Phone:317-988-2828
Mailing Address - Fax:
Practice Address - Street 1:1410 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46209-0001
Practice Address - Country:US
Practice Address - Phone:317-988-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013090A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist