Basic Information
| Provider Information | |||||||||
| NPI: | 1609812221 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RANDALLS FOOD & DRUGS LP | ||||||||
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| OtherOrganizationName: | RANDALLS PHARMACY #1013 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20427 N 27TH AVE # MSC4551 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850273241 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1407 S VOSS RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770571025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137831083 | ||||||||
| FaxNumber: | 7139753956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 05/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | RIVERS | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE PLAN SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6238693524 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAFEWAY INC | ||||||||
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| AuthorizedOfficialCredential: | CPHT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 22023 | TX | N | Suppliers | Pharmacy | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4580660 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 463670 | 05 | TX | MEDICAID |