MEDICARE: RANDALLS FOOD & DRUGS LP

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy	22116	TX
3	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4517542	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134158199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDALLS FOOD & DRUGS LP

Provider Business Mailing Address
First Line	:	250 E PARKCENTER BLVD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-3940
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4215 S CARRIER PKWY
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3203
Country	:	US
Telephone Number	:	972-266-7056
Fax Number	:	972-266-7087

Authorized Official
Title or Position	:	ENROLLMENTS MANAGER
Name	:	KATHY GIANNAKOPOULOS
Credential	:
Telephone Number	:	208-395-3954

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	07/05/2024

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