Provider Demographics
NPI:1770578312
Name:RICHARDSON, BILL MICHAEL (DPH)
Entity type:Individual
Prefix:
First Name:BILL
Middle Name:MICHAEL
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 ROLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-4301
Mailing Address - Country:US
Mailing Address - Phone:731-423-2272
Mailing Address - Fax:731-423-2174
Practice Address - Street 1:505 ROLAND AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-4301
Practice Address - Country:US
Practice Address - Phone:731-423-2272
Practice Address - Fax:731-423-2174
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1987183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4419708OtherNABP