1689603649 NPI number — RANDALLS FOOD & DRUGS LP

Table of content: DLANA SHEPHERD M.S., RBT (NPI 1790397651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689603649 NPI number — RANDALLS FOOD & DRUGS LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDALLS FOOD & DRUGS LP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1689603649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5918 STONERIDGE MALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLEASANTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94588-3229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-467-2806
Provider Business Mailing Address Fax Number:
925-467-2802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2755 N COLLINS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76006-3793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-276-5370
Provider Business Practice Location Address Fax Number:
817-276-5375
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELIOPULOS
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT MANAGER, ENROLLMENTS
Authorized Official Telephone Number:
208-395-3906

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  22101 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4547658 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 463798 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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