Provider Demographics
NPI:1700575230
Name:RANDOLPH, OLIVIA CLARK
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:CLARK
Last Name:RANDOLPH
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 1:10888 HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-4908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10033 US HIGHWAY 70 E
Practice Address - Street 2:
Practice Address - City:MC EWEN
Practice Address - State:TN
Practice Address - Zip Code:37101-4490
Practice Address - Country:US
Practice Address - Phone:931-582-8808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47523183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist