Healthcare Provider Details

I. General information

NPI: 1063643203
Provider Name (Legal Business Name): HEATH ASHLEY RANDALL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

IV. Provider business mailing address

15219 LORIE DR
GRASS VALLEY CA
95949-6413
US

V. Phone/Fax

Practice location:
  • Phone: 916-276-4734
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number62590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: