Provider Demographics
NPI:1417008061
Name:ELDE, RANDOLPH LEE (RPH, CDE)
Entity Type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:LEE
Last Name:ELDE
Suffix:
Gender:M
Credentials:RPH, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4101
Mailing Address - Country:US
Mailing Address - Phone:360-428-1710
Mailing Address - Fax:360-428-7847
Practice Address - Street 1:1223 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4101
Practice Address - Country:US
Practice Address - Phone:360-428-1710
Practice Address - Fax:360-428-7847
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist