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NPI Code Detail

MEDICARE: MR. RUDY LICUL RPH

MEDICARE: MR. RUDY LICUL RPH
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
1183500000XPharmacist040314-1NY

General Provider Information

NPI Number : 1528242716
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. RUDY LICUL RPH
Provider Business Mailing Address
First Line : 15129 22ND AVE
Second Line :
City : WHITESTONE
State : NY
Zip : 11357-3718
Country : US
Telephone Number : 718-762-3109
Fax Number : 718-939-2984
Provider Business Practice Location Address
First Line : 1516 WESTCHESTER AVE
Second Line :
City : BRONX
State : NY
Zip : 10472-2907
Country : US
Telephone Number : 718-861-2359
Fax Number : 718-939-2984
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/24/2007
Last Update Date : 12/24/2007

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