Healthcare Provider Details

I. General information

NPI: 1679118343
Provider Name (Legal Business Name): RANDOLPH ERNEST MARGRAVE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2019
Last Update Date: 11/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 RIDGEWOOD AVE STE C
HOLLY HILL FL
32117-5402
US

IV. Provider business mailing address

3742 CARDINAL BLVD
DAYTONA BEACH FL
32118-7204
US

V. Phone/Fax

Practice location:
  • Phone: 386-677-7377
  • Fax: 844-677-0739
Mailing address:
  • Phone: 386-451-7418
  • Fax: 844-677-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License NumberPU0002896
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPS0020769
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS0020769
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: