MEDICARE: MR. SCOTT RANDOLPH PROFIT RPH

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	183500000X	Pharmacist	5302026136	MI

General Provider Information

NPI Number	:	1790847333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT RANDOLPH PROFIT RPH

Provider Business Mailing Address
First Line	:	5805 LAMPLIGHTER LN
Second Line	:
City	:	MIDLAND
State	:	MI
Zip	:	48642-7131
Country	:	US
Telephone Number	:	989-486-1287
Fax Number	:

Provider Business Practice Location Address
First Line	:	2006 N SAGINAW RD
Second Line	:	RITE AID #1574
City	:	MIDLAND
State	:	MI
Zip	:	48640-6614
Country	:	US
Telephone Number	:	989-631-4321
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	05/13/2011

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