Provider Demographics
NPI:1134627490
Name:RICHARDSON, MARK GORDON
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:GORDON
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 1:35 HARRINGTON AVE UNIT 2413
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-5283
Mailing Address - Country:US
Mailing Address - Phone:315-399-0222
Mailing Address - Fax:
Practice Address - Street 1:720 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MA
Practice Address - Zip Code:01510-2430
Practice Address - Country:US
Practice Address - Phone:978-368-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH237921183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist