Provider Demographics
NPI:1578551735
Name:POOLE, RICHARD R (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:R
Last Name:POOLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 884
Mailing Address - Street 2:201 WEST SOUTH ST
Mailing Address - City:UNION
Mailing Address - State:SC
Mailing Address - Zip Code:29379-0884
Mailing Address - Country:US
Mailing Address - Phone:864-427-0615
Mailing Address - Fax:864-429-8045
Practice Address - Street 1:201 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-2836
Practice Address - Country:US
Practice Address - Phone:864-427-0615
Practice Address - Fax:864-429-8045
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD06410Medicaid
SCT24180Medicare UPIN
SCD06410Medicaid
SC0615130001Medicare NSC