Provider Demographics
NPI:1396143111
Name:RANDOLPH, BRETT ALAN (RPH, MBA)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:ALAN
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-394-9517
Mailing Address - Fax:419-394-6147
Practice Address - Street 1:200 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2400
Practice Address - Country:US
Practice Address - Phone:419-394-9517
Practice Address - Fax:419-394-6147
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03122371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist