Provider Demographics
NPI:1629467782
Name:CLEVELAND RANDOLPH, JR, MD, PA
Entity Type:Organization
Organization Name:CLEVELAND RANDOLPH, JR, MD, PA
Other - Org Name:C.W.RANDOLPH'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEVELAND
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-746-3046
Mailing Address - Street 1:1891 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2644
Mailing Address - Country:US
Mailing Address - Phone:904-746-3046
Mailing Address - Fax:904-249-2047
Practice Address - Street 1:1891 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-2644
Practice Address - Country:US
Practice Address - Phone:904-746-3046
Practice Address - Fax:904-249-2047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH28647333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH28647OtherPHARMACY LICENSE