Provider Demographics
NPI:1841222676
Name:RANDALLS FOOD & DRUGS LP
Entity Type:Organization
Organization Name:RANDALLS FOOD & DRUGS LP
Other - Org Name:TOM THUMB PHARMACY #3625
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:208-395-3920
Mailing Address - Fax:623-336-6896
Practice Address - Street 1:302 S PARK BLVD
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7835
Practice Address - Country:US
Practice Address - Phone:817-481-2598
Practice Address - Fax:817-421-9359
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAFEWAY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-06
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22095333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX463766Medicaid
4585646OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TXPHC014Medicare PIN
TXP00229903Medicare PIN
4585646OtherOTHER ID NUMBER-COMMERCIAL NUMBER