Provider Demographics
NPI:1902974355
Name:RICHARDS, MARK J (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-1119
Mailing Address - Country:US
Mailing Address - Phone:515-274-4001
Mailing Address - Fax:515-274-5471
Practice Address - Street 1:5625 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-1119
Practice Address - Country:US
Practice Address - Phone:515-274-4001
Practice Address - Fax:515-274-5471
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14248183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist