Provider Demographics
NPI:1548583230
Name:RANDOLPH, DANIEL (RPH)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:
Other - Last Name:RANDOLPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4915 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-2501
Mailing Address - Country:US
Mailing Address - Phone:502-448-9726
Mailing Address - Fax:502-448-4991
Practice Address - Street 1:4915 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2501
Practice Address - Country:US
Practice Address - Phone:502-448-9726
Practice Address - Fax:502-448-4991
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011919183500000X
IN26015022A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist