Provider Demographics
NPI:1710235304
Name:WALLSTEN, RICHARD L JR (PHARMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:WALLSTEN
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 MANITOU RD
Mailing Address - Street 2:
Mailing Address - City:ST. JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-985-3685
Mailing Address - Fax:
Practice Address - Street 1:754 MANITOU RD
Practice Address - Street 2:
Practice Address - City:ST. JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-985-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030883183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist