Provider Demographics
NPI:1578971560
Name:FOSEN, RICHARD (BS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:FOSEN
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1364
Mailing Address - Country:US
Mailing Address - Phone:815-383-8681
Mailing Address - Fax:
Practice Address - Street 1:505 RIVERSTONE PKWY
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-7207
Practice Address - Country:US
Practice Address - Phone:815-802-3166
Practice Address - Fax:815-808-3168
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051030463183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist