Provider Demographics
NPI:1083739254
Name:NELAN LLC
Entity Type:Organization
Organization Name:NELAN LLC
Other - Org Name:RANDOLPH MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KUNTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LALA
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:704-365-0707
Mailing Address - Street 1:3541 RANDOLPH RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1082
Mailing Address - Country:US
Mailing Address - Phone:704-365-0707
Mailing Address - Fax:704-442-9870
Practice Address - Street 1:3541 RANDOLPH RD
Practice Address - Street 2:SUITE 104
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1082
Practice Address - Country:US
Practice Address - Phone:704-365-0707
Practice Address - Fax:704-442-9870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
NC094903336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7N9490Medicaid
NC0605998Medicaid
2068170OtherPK
SC7N9490Medicaid