MEDICARE: MR. RANDALL KEVIN WEIDNER RPH

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	14306	NV

General Provider Information

NPI Number	:	1538442967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDALL KEVIN WEIDNER RPH

Provider Business Mailing Address
First Line	:	3339 LAS VEGAS BLVD S
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-1401
Country	:	US
Telephone Number	:	702-369-8166
Fax Number	:	702-369-9524

Provider Business Practice Location Address
First Line	:	3339 LAS VEGAS BLVD S
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-1401
Country	:	US
Telephone Number	:	702-369-8166
Fax Number	:	702-369-9524

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

Provider Enumeration Date	:	09/22/2011
Last Update Date	:	09/22/2011

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