Provider Demographics
NPI:1245830041
Name:CRISP, RANDALL (RPH)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:CRISP
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 1:114 COUNTRYRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-1080
Mailing Address - Country:US
Mailing Address - Phone:740-506-2658
Mailing Address - Fax:
Practice Address - Street 1:70 HOSPITALITY DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2779
Practice Address - Country:US
Practice Address - Phone:937-376-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-12123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist