Provider Demographics
NPI:1134719594
Name:RICHARDS, JACK (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:RICHARDS
Suffix:
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 1:5 CABOT RD UNIT 125
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5281
Mailing Address - Country:US
Mailing Address - Phone:518-428-5670
Mailing Address - Fax:
Practice Address - Street 1:718 SMYTH RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-7007
Practice Address - Country:US
Practice Address - Phone:603-624-4366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065049183500000X
MAPH237762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist