Provider Demographics
NPI:1275896144
Name:RANDALL, DENISE (RPH)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20086 BANNISTER DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5942
Mailing Address - Country:US
Mailing Address - Phone:586-228-1361
Mailing Address - Fax:
Practice Address - Street 1:31200 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-7048
Practice Address - Country:US
Practice Address - Phone:586-294-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-16
Last Update Date:2012-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist