Healthcare Provider Details

I. General information

NPI: 1891229159
Provider Name (Legal Business Name): RANDAL KOCH RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 SOUTH TAFT AVENUE
FREMONT OH
43420
US

IV. Provider business mailing address

715 SOUTH TAFT AVENUE
FREMONT OH
43420
US

V. Phone/Fax

Practice location:
  • Phone: 419-333-2735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03-2-15615
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: