Provider Demographics
NPI:1013936350
Name:JAYNE, RANDY DUANE (RPH)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:DUANE
Last Name:JAYNE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22124 DROVER WAY
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-7608
Mailing Address - Country:US
Mailing Address - Phone:951-244-6886
Mailing Address - Fax:
Practice Address - Street 1:1035 W RAMSEY ST STE B3
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4400
Practice Address - Country:US
Practice Address - Phone:951-849-4920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH38586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA438830Medicaid
CA8837032Medicare ID - Type Unspecified