Provider Demographics
NPI:1285925388
Name:MCCROCKLIN, RICHARD WAYNE (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WAYNE
Last Name:MCCROCKLIN
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 1:410 W. TOM T. HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164
Mailing Address - Country:US
Mailing Address - Phone:606-286-2322
Mailing Address - Fax:606-286-1603
Practice Address - Street 1:410 WEST TOM T HALL BLVD
Practice Address - Street 2:
Practice Address - City:OLIVE HILL
Practice Address - State:KY
Practice Address - Zip Code:41164
Practice Address - Country:US
Practice Address - Phone:606-286-2322
Practice Address - Fax:606-286-1603
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY009008183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist