Provider Demographics
NPI:1912339649
Name:RANDOLPH, MONA LISA (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MONA
Middle Name:LISA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 W AMARILLO BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-4141
Mailing Address - Country:US
Mailing Address - Phone:806-352-6650
Mailing Address - Fax:806-352-7833
Practice Address - Street 1:5601 W AMARILLO BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4141
Practice Address - Country:US
Practice Address - Phone:806-352-6650
Practice Address - Fax:806-352-7833
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist