Provider Demographics
NPI:1144598236
Name:EDGERSON, RANDALL KIRK (PHARM D)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:KIRK
Last Name:EDGERSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5199 N KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1518
Mailing Address - Country:US
Mailing Address - Phone:317-257-4845
Mailing Address - Fax:317-255-3764
Practice Address - Street 1:5199 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1518
Practice Address - Country:US
Practice Address - Phone:317-257-4845
Practice Address - Fax:317-255-3764
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016783A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist