Provider Demographics
NPI:1174000939
Name:POULSEN, TAYLOR RANDI (PHARMD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RANDI
Last Name:POULSEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10947 W ROYAL PALM RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-1900
Mailing Address - Country:US
Mailing Address - Phone:608-718-9755
Mailing Address - Fax:
Practice Address - Street 1:15514 W WADDELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-5167
Practice Address - Country:US
Practice Address - Phone:623-215-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023265183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist