MEDICARE: DR. KELLY M RUDD PHARM.D., BCPS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	19713	IA
2	1835P1200X	Pharmacotherapy Pharmacist	050193	NY
3	183500000X	Pharmacist	19454	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19434	OTHER	OK	OKLAHOMA STATE BOARD OF PHARMACY

General Provider Information

NPI Number	:	1508841222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY M RUDD PHARM.D., BCPS

Provider Business Mailing Address
First Line	:	34794 S HIGHWAY 82
Second Line	:
City	:	VINITA
State	:	OK
Zip	:	74301-7045
Country	:	US
Telephone Number	:	315-717-3268
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 W 17TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74107-1886
Country	:	US
Telephone Number	:	185-618-2399
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	04/17/2025

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Directions to “ DR. KELLY M RUDD PHARM.D., BCPS” Practice Location

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