Provider Demographics
NPI:1699375063
Name:RANDALL, ROBERT JOSEPH (DPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:RANDALL
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 1:408 LILAC PL
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-3516
Mailing Address - Country:US
Mailing Address - Phone:580-977-9242
Mailing Address - Fax:
Practice Address - Street 1:5505 W OWEN K GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-6075
Practice Address - Country:US
Practice Address - Phone:580-233-9948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11823183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist