Provider Demographics
NPI:1609812221
Name:RANDALLS FOOD & DRUGS LP
Entity Type:Organization
Organization Name:RANDALLS FOOD & DRUGS LP
Other - Org Name:RANDALLS PHARMACY #1013
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE PLAN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:623-869-3524
Mailing Address - Street 1:20427 N 27TH AVE # MSC4551
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1407 S VOSS RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-1025
Practice Address - Country:US
Practice Address - Phone:713-783-1083
Practice Address - Fax:713-975-3956
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAFEWAY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-21
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22023333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4580660OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX463670Medicaid
TXP00229903Medicare PIN
TX463670Medicaid
TXPHC014Medicare PIN