Provider Demographics
NPI:1922392125
Name:MACK, RANDY J (RPH)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:J
Last Name:MACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6100 SHINGLE CREEK PKWY
Mailing Address - Street 2:T0240
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6100 SHINGLE CREEK PKWY
Practice Address - Street 2:T0240
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2110
Practice Address - Country:US
Practice Address - Phone:763-566-0143
Practice Address - Fax:763-566-0143
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN115304183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist