Provider Demographics
NPI:1154609774
Name:JAKE, RANDELL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:RANDELL
Middle Name:
Last Name:JAKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 UNSER BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4640
Mailing Address - Country:US
Mailing Address - Phone:505-792-1992
Mailing Address - Fax:505-792-1990
Practice Address - Street 1:10700 UNSER BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4640
Practice Address - Country:US
Practice Address - Phone:505-792-1992
Practice Address - Fax:505-792-1990
Is Sole Proprietor?:No
Enumeration Date:2011-07-31
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist