=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053031369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDYS PHARMACY (LTC)
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2022
-----------------------------------------------------
Last Update Date | 08/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1310 MAIN ST
-----------------------------------------------------
City | WOODWARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73801-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-256-6600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1310 MAIN ST
-----------------------------------------------------
City | WOODWARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73801-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-256-6600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PIC, OWNER
-----------------------------------------------------
Name | MEGAN SWAYZE
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 580-256-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------