Provider Demographics
NPI:1295081032
Name:RANDALL, NANCY TIDWELL
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:TIDWELL
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 LEESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-2136
Mailing Address - Country:US
Mailing Address - Phone:859-259-0965
Mailing Address - Fax:859-259-0971
Practice Address - Street 1:1600 LEESTOWN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-2136
Practice Address - Country:US
Practice Address - Phone:859-259-0965
Practice Address - Fax:859-259-0971
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist