Provider Demographics
NPI:1669077897
Name:RICHARDSON, DANTEL
Entity type:Individual
Prefix:
First Name:DANTEL
Middle Name:
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 1:10115 GRAND BAY WILMER RD S
Mailing Address - Street 2:
Mailing Address - City:GRAND BAY
Mailing Address - State:AL
Mailing Address - Zip Code:36541-5024
Mailing Address - Country:US
Mailing Address - Phone:251-865-6128
Mailing Address - Fax:251-865-5400
Practice Address - Street 1:10115 GRAND BAY WILMER RD S
Practice Address - Street 2:
Practice Address - City:GRAND BAY
Practice Address - State:AL
Practice Address - Zip Code:36541-5024
Practice Address - Country:US
Practice Address - Phone:251-865-6128
Practice Address - Fax:251-865-5400
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist