Provider Demographics
NPI:1205127453
Name:HANNA, RANDALL THOMAS (RPH)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:THOMAS
Last Name:HANNA
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 1:5312 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-5658
Mailing Address - Country:US
Mailing Address - Phone:952-440-5433
Mailing Address - Fax:
Practice Address - Street 1:1000 NICOLLET MALL
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2542
Practice Address - Country:US
Practice Address - Phone:612-696-6516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist