Provider Demographics
NPI:1841042116
Name:BROTHERTON, RANDALL JAMES
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:JAMES
Last Name:BROTHERTON
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 1:827 FM 1304
Mailing Address - Street 2:
Mailing Address - City:AQUILLA
Mailing Address - State:TX
Mailing Address - Zip Code:76622-2563
Mailing Address - Country:US
Mailing Address - Phone:254-495-7252
Mailing Address - Fax:
Practice Address - Street 1:301 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1754
Practice Address - Country:US
Practice Address - Phone:469-800-8324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130145183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician