Provider Demographics
NPI:1538203229
Name:BLANK, RICHARD (RPH)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BLANK
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 1:555 N MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-672-3741
Mailing Address - Fax:
Practice Address - Street 1:555 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3630
Practice Address - Country:US
Practice Address - Phone:307-672-3741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist