Provider Demographics
NPI:1346514510
Name:CROCKER, RICHARD (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:CROCKER
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33961 DOHENY PARK RD
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4835
Mailing Address - Country:US
Mailing Address - Phone:949-240-9573
Mailing Address - Fax:949-240-9601
Practice Address - Street 1:33961 DOHENY PARK RD
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-4835
Practice Address - Country:US
Practice Address - Phone:949-240-9573
Practice Address - Fax:949-240-9601
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 27514183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist