Provider Demographics
NPI:1316045347
Name:RANDOLPHS RX PHARMACY
Entity Type:Organization
Organization Name:RANDOLPHS RX PHARMACY
Other - Org Name:RANDOLPHS RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ PIC
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:773-434-7186
Mailing Address - Street 1:2751 W 51ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-2136
Mailing Address - Country:US
Mailing Address - Phone:773-434-7186
Mailing Address - Fax:773-778-7585
Practice Address - Street 1:2751 W 51ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-2136
Practice Address - Country:US
Practice Address - Phone:773-434-7186
Practice Address - Fax:773-778-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IL0540116193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2020858OtherPK
2020858OtherPK
0685400001Medicare NSC