Provider Demographics
NPI:1407853609
Name:MALAN, RANDY DALE (RPH)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DALE
Last Name:MALAN
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 1:512 HUNTINGTON
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1952
Mailing Address - Country:US
Mailing Address - Phone:618-288-4520
Mailing Address - Fax:
Practice Address - Street 1:401 N 4TH ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5255
Practice Address - Country:US
Practice Address - Phone:217-785-8983
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric