Provider Demographics
NPI:1982974127
Name:PHILLIPS, RANDAL WAYNE
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:WAYNE
Last Name:PHILLIPS
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 1:1120 TAMIAMI TRL N
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-2158
Mailing Address - Country:US
Mailing Address - Phone:941-441-2909
Mailing Address - Fax:941-488-3247
Practice Address - Street 1:1120 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-2158
Practice Address - Country:US
Practice Address - Phone:941-441-2909
Practice Address - Fax:941-488-3247
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0026967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist