Provider Demographics
NPI:1760661375
Name:BRENNER, RANDAL C (RPH)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:C
Last Name:BRENNER
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 1:261 HICKORY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-6636
Mailing Address - Country:US
Mailing Address - Phone:407-227-8870
Mailing Address - Fax:
Practice Address - Street 1:472 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2548
Practice Address - Country:US
Practice Address - Phone:770-535-3750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0146431835P0018X
FLPS21974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS21974OtherPHARMACIST LISCENSE
GARPH014643OtherPHARMACIST