Provider Demographics
NPI:1558495879
Name:BUCHANAN, RANDALL MAXIE JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:MAXIE
Last Name:BUCHANAN
Suffix:JR
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 1:724 NE COSMOS DR
Mailing Address - Street 2:
Mailing Address - City:PINETTA
Mailing Address - State:FL
Mailing Address - Zip Code:32350-3017
Mailing Address - Country:US
Mailing Address - Phone:850-929-2054
Mailing Address - Fax:
Practice Address - Street 1:1219 W BASE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-1413
Practice Address - Country:US
Practice Address - Phone:850-973-3219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS28160183500000X
GARPH017201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist