MEDICARE: MR. RANDY PON SIM PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	66206	TX

General Provider Information

NPI Number	:	1083387419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDY PON SIM PHARMD

Provider Business Mailing Address
First Line	:	5630 N DESERT BLVD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-1636
Country	:	US
Telephone Number	:	915-845-1422
Fax Number	:

Provider Business Practice Location Address
First Line	:	5630 N DESERT BLVD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-1636
Country	:	US
Telephone Number	:	915-845-1422
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2021
Last Update Date	:	07/30/2021

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