Provider Demographics
NPI:1720675713
Name:DUVALL, RANDY L
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:L
Last Name:DUVALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8121 MIDLOTHIAN TPKE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-5115
Mailing Address - Country:US
Mailing Address - Phone:804-560-9481
Mailing Address - Fax:
Practice Address - Street 1:8121 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-5115
Practice Address - Country:US
Practice Address - Phone:804-560-9481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202006368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA05Medicaid