Provider Demographics
NPI:1861864266
Name:RADTKE, RANDALL TROY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:TROY
Last Name:RADTKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 E PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-3609
Mailing Address - Country:US
Mailing Address - Phone:619-477-7114
Mailing Address - Fax:619-477-7480
Practice Address - Street 1:1201 E PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3609
Practice Address - Country:US
Practice Address - Phone:619-477-7114
Practice Address - Fax:619-477-7480
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-24
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65960183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist