Provider Demographics
NPI:1477617439
Name:RANDOLPH, DAVID L (RP)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-2342
Mailing Address - Country:US
Mailing Address - Phone:308-760-2287
Mailing Address - Fax:
Practice Address - Street 1:2101 BOX BUTTE AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-4445
Practice Address - Country:US
Practice Address - Phone:308-762-6660
Practice Address - Fax:308-762-1923
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10869183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist