Provider Demographics
NPI:1053313908
Name:REZNOR, RANDALL WILBERT (RPH)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:WILBERT
Last Name:REZNOR
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 1:210107 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:GERING
Mailing Address - State:NE
Mailing Address - Zip Code:69341-6711
Mailing Address - Country:US
Mailing Address - Phone:308-436-7406
Mailing Address - Fax:
Practice Address - Street 1:4021 AVENUE B
Practice Address - Street 2:REGIONAL WEST MEDICAL CENTER
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4602
Practice Address - Country:US
Practice Address - Phone:308-630-1262
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist