Provider Demographics
NPI:1730783176
Name:RICHARDSON, DAREL (PHARMD)
Entity type:Individual
Prefix:
First Name:DAREL
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:MS
Mailing Address - Zip Code:39555-0789
Mailing Address - Country:US
Mailing Address - Phone:228-588-6053
Mailing Address - Fax:228-588-9396
Practice Address - Street 1:7021 HWY 614
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:MS
Practice Address - Zip Code:39555-0789
Practice Address - Country:US
Practice Address - Phone:228-588-6053
Practice Address - Fax:228-588-9396
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-16758183500000X
AL21543183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1730783176Medicaid