Provider Demographics
NPI:1336424860
Name:RICHARD, JUSTIN L
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:L
Last Name:RICHARD
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 1:295 ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4148
Mailing Address - Country:US
Mailing Address - Phone:401-273-7675
Mailing Address - Fax:401-273-4761
Practice Address - Street 1:295 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4148
Practice Address - Country:US
Practice Address - Phone:401-273-7675
Practice Address - Fax:401-273-4761
Is Sole Proprietor?:No
Enumeration Date:2011-10-16
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH04202183500000X
MAPH25947183500000X
CTPCT.0009455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist