Provider Demographics
NPI:1487073524
Name:WILBER, RANDALL LEE (RPH)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:LEE
Last Name:WILBER
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 1:522 W FINNIE FLAT RD
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-7265
Mailing Address - Country:US
Mailing Address - Phone:928-567-2274
Mailing Address - Fax:
Practice Address - Street 1:522 W FINNIE FLAT RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7265
Practice Address - Country:US
Practice Address - Phone:928-567-2274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS07272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist