Provider Demographics
NPI:1144545732
Name:INGERSOLL, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:INGERSOLL
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 1:60 E 82ND ST
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-8005
Mailing Address - Country:US
Mailing Address - Phone:231-652-7820
Mailing Address - Fax:
Practice Address - Street 1:60 E 82ND ST
Practice Address - Street 2:
Practice Address - City:NEWAYGO
Practice Address - State:MI
Practice Address - Zip Code:49337-8005
Practice Address - Country:US
Practice Address - Phone:231-652-7820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist