Provider Demographics
NPI:1679118343
Name:MARGRAVE, RANDOLPH ERNEST (RPH)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:ERNEST
Last Name:MARGRAVE
Suffix:
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 1:3742 CARDINAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-7204
Mailing Address - Country:US
Mailing Address - Phone:386-451-7418
Mailing Address - Fax:844-677-0739
Practice Address - Street 1:1702 RIDGEWOOD AVE STE C
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-5402
Practice Address - Country:US
Practice Address - Phone:386-677-7377
Practice Address - Fax:844-677-0739
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-16
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPU00028961835N1003X
FLPS00207691835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS0020769OtherBOARD OF PHARMACY