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NPI Code Detail

MEDICARE: JACK RANDOLPH

MEDICARE: JACK RANDOLPH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacistPS54350FL

General Provider Information

NPI Number : 1134730104
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACK RANDOLPH
Provider Business Mailing Address
First Line : 2237 W NINE MILE RD
Second Line :
City : PENSACOLA
State : FL
Zip : 32534-9416
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2237 W NINE MILE RD
Second Line :
City : PENSACOLA
State : FL
Zip : 32534-9416
Country : US
Telephone Number : 850-473-0286
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/13/2020
Last Update Date : 08/13/2020

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Directions to “ JACK RANDOLPH ” Practice Location

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