Provider Demographics
NPI:1336497338
Name:RANDOLPH, MYRA YOLANDA (RPH)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:YOLANDA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2872
Mailing Address - Country:US
Mailing Address - Phone:803-786-0158
Mailing Address - Fax:803-333-9582
Practice Address - Street 1:3700 TWO NOTCH RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2872
Practice Address - Country:US
Practice Address - Phone:803-786-0158
Practice Address - Fax:803-333-9582
Is Sole Proprietor?:No
Enumeration Date:2012-08-22
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6131183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist