Provider Demographics
NPI:1306421607
Name:FILLMORE, RICHARD BROCK (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:BROCK
Last Name:FILLMORE
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 1:3 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1822
Mailing Address - Country:US
Mailing Address - Phone:304-736-2451
Mailing Address - Fax:304-736-8519
Practice Address - Street 1:3 MALL RD
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1822
Practice Address - Country:US
Practice Address - Phone:304-736-2451
Practice Address - Fax:304-736-8519
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist