Provider Demographics
NPI:1952327108
Name:RANDOLPH MEDICAL PLUS LLC
Entity Type:Organization
Organization Name:RANDOLPH MEDICAL PLUS LLC
Other - Org Name:RANDOLPH DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENTON
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-449-2700
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64469-0235
Mailing Address - Country:US
Mailing Address - Phone:816-449-2700
Mailing Address - Fax:816-449-5624
Practice Address - Street 1:301 S POLK ST
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:MO
Practice Address - Zip Code:64469-4037
Practice Address - Country:US
Practice Address - Phone:816-449-2700
Practice Address - Fax:816-449-5624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010240103336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600284814Medicaid