Provider Demographics
NPI:1407469281
Name:RICHARDSON, THERON
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:
Last Name:RICHARDSON
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 1:701 HARRISON ST APT 111
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-3043
Mailing Address - Country:US
Mailing Address - Phone:347-817-9594
Mailing Address - Fax:
Practice Address - Street 1:1241 BLAKESLEE BOULEVARD DR E STE 2
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-2401
Practice Address - Country:US
Practice Address - Phone:570-386-5838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP454775183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist