MEDICARE: RANDALLS FOOD & DRUGS LP

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
1	332B00000X	Durable Medical Equipment & Medical Supplies	22092	TX
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4583870	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1730118704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDALLS FOOD & DRUGS LP

Provider Business Mailing Address
First Line	:	250 E PARKCENTER BLVD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-3940
Country	:	US
Telephone Number	:	208-395-3920
Fax Number	:	623-336-6896

Provider Business Practice Location Address
First Line	:	4010 N MACARTHUR BLVD STE 100
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75038-6413
Country	:	US
Telephone Number	:	972-650-2090
Fax Number	:	972-541-0284

Authorized Official
Title or Position	:	ASSISTANT MANAGER, ENROLLMENTS
Name	:	TIFFANY ELIOPULOS
Credential	:
Telephone Number	:	208-395-3906

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	10/03/2018

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Directions to “RANDALLS FOOD & DRUGS LP ” Practice Location

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