Provider Demographics
NPI:1639456684
Name:RICHARDSON, JOHN A
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
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 1:12085 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-9761
Mailing Address - Country:US
Mailing Address - Phone:616-901-4661
Mailing Address - Fax:866-365-7331
Practice Address - Street 1:6370 LAKE MICHIGAN DR
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-8068
Practice Address - Country:US
Practice Address - Phone:616-895-7426
Practice Address - Fax:866-365-7331
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist