Provider Demographics
NPI:1033495544
Name:ARNDORFER, RANDALL LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:LEE
Last Name:ARNDORFER
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:N5821 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53178-9746
Mailing Address - Country:US
Mailing Address - Phone:262-593-2848
Mailing Address - Fax:
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1831
Practice Address - Country:US
Practice Address - Phone:920-568-9326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI887340183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33284000Medicaid