Healthcare Provider Details

I. General information

NPI: 1407853609
Provider Name (Legal Business Name): RANDY DALE MALAN R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N 4TH ST FIRST FLOOR
SPRINGFIELD IL
62702-5255
US

IV. Provider business mailing address

512 HUNTINGTON
GLEN CARBON IL
62034-1952
US

V. Phone/Fax

Practice location:
  • Phone: 217-785-8983
  • Fax:
Mailing address:
  • Phone: 618-288-4520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: