Provider Demographics
NPI:1992238612
Name:TATE, DAVID RANDALL
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RANDALL
Last Name:TATE
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 1:4909 JOHNSON RD
Mailing Address - Street 2:PHARMACIST
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-2547
Mailing Address - Country:US
Mailing Address - Phone:940-687-8625
Mailing Address - Fax:940-691-7574
Practice Address - Street 1:4909 JOHNSON RD
Practice Address - Street 2:PHARMACIST
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-2547
Practice Address - Country:US
Practice Address - Phone:940-687-8625
Practice Address - Fax:940-691-7574
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29109183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist