Provider Demographics
NPI:1043595689
Name:JENNINGS, RANDY JAMES
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:JAMES
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 DENALI CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9116
Mailing Address - Country:US
Mailing Address - Phone:260-482-8187
Mailing Address - Fax:
Practice Address - Street 1:923 NORTHCREST BUSINESS CENTER
Practice Address - Street 2:6-D
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-484-8542
Practice Address - Fax:260-484-1094
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021033A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist