1417550856 NPI number — DR. HOLLY RENEE RANDOLPH PHARMD

Table of content: DR. HOLLY RENEE RANDOLPH PHARMD (NPI 1417550856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417550856 NPI number — DR. HOLLY RENEE RANDOLPH PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDOLPH
Provider First Name:
HOLLY
Provider Middle Name:
RENEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417550856
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2861 FM 17
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND SALINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-274-5661
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 N 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLS POINT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75169-2040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-873-2538
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  67272 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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