Healthcare Provider Details

I. General information

NPI: 1124775168
Provider Name (Legal Business Name): RANDYN SHAMAR MCMILLAN CO, LDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 S FERDON BLVD
CRESTVIEW FL
32536-5252
US

IV. Provider business mailing address

4100 S FERDON BLVD STE C2
CRESTVIEW FL
32536-5287
US

V. Phone/Fax

Practice location:
  • Phone: 850-204-4762
  • Fax:
Mailing address:
  • Phone: 850-204-4762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO7360
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code156FX1900X
TaxonomyOrthoptist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO002944
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDPO3507
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: