Provider Demographics
NPI:1417167560
Name:MISTICHELLI, RICHARD A JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:MISTICHELLI
Suffix:JR
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 1:77 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-6245
Mailing Address - Country:US
Mailing Address - Phone:908-247-7368
Mailing Address - Fax:
Practice Address - Street 1:794 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3221
Practice Address - Country:US
Practice Address - Phone:973-483-4749
Practice Address - Fax:973-482-0643
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02615100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI02615100OtherPHARMACIST