Provider Demographics
NPI:1659887495
Name:SHANECK, RANDY JOHN (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:JOHN
Last Name:SHANECK
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:KROGER PHARMACY 3300 NAVARRE AVE
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616
Mailing Address - Country:US
Mailing Address - Phone:419-691-7034
Mailing Address - Fax:
Practice Address - Street 1:3300 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616
Practice Address - Country:US
Practice Address - Phone:419-691-7034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03129415183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist