Provider Demographics
NPI:1750447967
Name:HUDDLESTON, RANDY GENE
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:GENE
Last Name:HUDDLESTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 HIDDEN VALLEY CV
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-7714
Mailing Address - Country:US
Mailing Address - Phone:731-967-1466
Mailing Address - Fax:
Practice Address - Street 1:547 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-1703
Practice Address - Country:US
Practice Address - Phone:731-968-2647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10136183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist