Provider Demographics
NPI:1215765037
Name:BRUNSON, RANDILYN
Entity type:Individual
Prefix:
First Name:RANDILYN
Middle Name:
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 STONEGATE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-2463
Mailing Address - Country:US
Mailing Address - Phone:985-413-3467
Mailing Address - Fax:
Practice Address - Street 1:1172 NORTH AR 7
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834
Practice Address - Country:US
Practice Address - Phone:479-229-2502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD17050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist