Provider Demographics
NPI:1255620001
Name:PUTVIN, RICHARD JOHN
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:PUTVIN
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 1:4519 RICHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48506-2017
Mailing Address - Country:US
Mailing Address - Phone:810-250-0165
Mailing Address - Fax:
Practice Address - Street 1:4519 RICHFIELD RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48506-2017
Practice Address - Country:US
Practice Address - Phone:810-250-0165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist