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	22137	TX
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4500636	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891724852
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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 S HULEN ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76109-1929
Country	:	US
Telephone Number	:	817-570-2960
Fax Number	:	817-570-2965

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	:	11/02/2018

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Directions to “RANDALLS FOOD & DRUGS LP ” Practice Location

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