Provider Demographics
NPI:1316247141
Name:JIMENEZ, RANDY SAYURIN
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:SAYURIN
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5202
Mailing Address - Country:US
Mailing Address - Phone:619-222-9736
Mailing Address - Fax:
Practice Address - Street 1:3645 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5202
Practice Address - Country:US
Practice Address - Phone:619-222-9736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 63184183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist