Provider Demographics
NPI:1508335456
Name:WILLIS, RANDAL (RPH)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:WILLIS
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 1:1310 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-3002
Mailing Address - Country:US
Mailing Address - Phone:580-256-6600
Mailing Address - Fax:580-254-2835
Practice Address - Street 1:1310 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-3002
Practice Address - Country:US
Practice Address - Phone:580-256-6600
Practice Address - Fax:580-254-2835
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist