Provider Demographics
NPI:1215421227
Name:RANDAL RIVERSIDE CORPORATION
Entity type:Organization
Organization Name:RANDAL RIVERSIDE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRAFUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-557-3900
Mailing Address - Street 1:3360 MATLOCK RD # 100
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-2907
Mailing Address - Country:US
Mailing Address - Phone:817-557-3900
Mailing Address - Fax:817-557-3903
Practice Address - Street 1:3360 MATLOCK RD # 100
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2907
Practice Address - Country:US
Practice Address - Phone:817-557-3900
Practice Address - Fax:817-557-3903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX361253336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy