Provider Demographics
NPI:1467635607
Name:SMITH, RANDALL ROBERT (RPH)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:ROBERT
Last Name:SMITH
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 1:100 EAGLE ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5524
Mailing Address - Country:US
Mailing Address - Phone:716-626-9111
Mailing Address - Fax:
Practice Address - Street 1:13203 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALDEN
Practice Address - State:NY
Practice Address - Zip Code:14004-1312
Practice Address - Country:US
Practice Address - Phone:716-937-9818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033081183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist