Provider Demographics
NPI:1356896864
Name:HAINES, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:HAINES
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 1:125 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2902
Mailing Address - Country:US
Mailing Address - Phone:856-720-0464
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:215-823-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03253900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist