Provider Demographics
NPI:1801409156
Name:RICHARDSON, AUSTIN HEATH
Entity Type:Individual
Prefix:MR
First Name:AUSTIN
Middle Name:HEATH
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 1:1130 14TH ST APT 332
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-4064
Mailing Address - Country:US
Mailing Address - Phone:304-270-6279
Mailing Address - Fax:
Practice Address - Street 1:1538 CHARLESTON AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701
Practice Address - Country:US
Practice Address - Phone:304-696-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVIN0009747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist