Provider Demographics
NPI:1578874152
Name:SMITH, RANDAL MARK (DPH)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:MARK
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CANTERBURY ROAD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7105
Mailing Address - Country:US
Mailing Address - Phone:715-552-1752
Mailing Address - Fax:
Practice Address - Street 1:2424 E CLAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6773
Practice Address - Country:US
Practice Address - Phone:715-834-7380
Practice Address - Fax:715-834-1034
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13807-040183500000X
MO042252183500000X
OK9562183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist