Provider Demographics
NPI:1164438206
Name:ROBIN, WALLACE RANDAL (RPH)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:RANDAL
Last Name:ROBIN
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 1:1039 N TWIN CITY HWY
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-3828
Mailing Address - Country:US
Mailing Address - Phone:409-727-8660
Mailing Address - Fax:409-727-8670
Practice Address - Street 1:1039 N TWIN CITY HWY
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-3828
Practice Address - Country:US
Practice Address - Phone:409-727-8660
Practice Address - Fax:409-727-8670
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist