Provider Demographics
NPI:1770512733
Name:RANDALLS FOOD & DRUGS LP
Entity Type:Organization
Organization Name:RANDALLS FOOD & DRUGS LP
Other - Org Name:RANDALLS PHARMACY #2636
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT MANAGER, ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIOPULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3906
Mailing Address - Street 1:250 E PARKCENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2051 GATTIS SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7441
Practice Address - Country:US
Practice Address - Phone:512-246-0510
Practice Address - Fax:512-218-9136
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAFEWAY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-02
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23161332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX465612Medicaid
4535122OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4535122OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX0879960145Medicare NSC
TXP00229903Medicare PIN