Basic Information
| Provider Information | |||||||||
| NPI: | 1770512733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RANDALLS FOOD & DRUGS LP | ||||||||
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| OtherOrganizationName: | RANDALLS PHARMACY #2636 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 E PARKCENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063940 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2051 GATTIS SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786647441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122460510 | ||||||||
| FaxNumber: | 5122189136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 10/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | ELIOPULOS | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT MANAGER, ENROLLMENTS | ||||||||
| AuthorizedOfficialTelephone: | 2083953906 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAFEWAY INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 23161 | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 465612 | 05 | TX | MEDICAID | 4535122 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |