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	333600000X	Pharmacy	22087	TX
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4573855	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659300622
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDALLS FOOD & DRUGS LP

Provider Business Mailing Address
First Line	:	20427 N 27TH AVE # MSC4551
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-3241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4720 BRYANT IRVIN RD
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76132-3604
Country	:	US
Telephone Number	:	817-294-9994
Fax Number	:	817-370-6459

Authorized Official
Title or Position	:	MANAGED CARE PLAN SPECIALIST
Name	:	MICHELLE ANN RIVERS
Credential	:	CPHT
Telephone Number	:	623-869-3524

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	05/26/2017

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