Provider Demographics
NPI:1952754707
Name:RANDOLPH, SAMUEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:TN
Mailing Address - Zip Code:37361-0297
Mailing Address - Country:US
Mailing Address - Phone:423-299-9029
Mailing Address - Fax:423-299-9250
Practice Address - Street 1:186 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:TN
Practice Address - Zip Code:37361
Practice Address - Country:US
Practice Address - Phone:423-299-9029
Practice Address - Fax:423-299-9250
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist