=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972420917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE WIG DOCTOR RX FLORIDA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2026
-----------------------------------------------------
Last Update Date | 07/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5621 COMMERCE ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32211-5257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-480-0189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9061 WESTERN WAY UNIT 4
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-0380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-480-0189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. RANDE HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-480-0189
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------