Provider Demographics
NPI:1174806798
Name:CONLEY, RANDALL S (RPH)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:S
Last Name:CONLEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3247
Mailing Address - Country:US
Mailing Address - Phone:507-645-0404
Mailing Address - Fax:
Practice Address - Street 1:401 5TH ST W
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-1700
Practice Address - Country:US
Practice Address - Phone:507-645-9658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113988183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist