Healthcare Provider Details

I. General information

NPI: 1508433442
Provider Name (Legal Business Name): ELLEN BRIDGET CUDAK RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 BERLIN TPKE
NEWINGTON CT
06111-5106
US

IV. Provider business mailing address

10-D QUEEN TERRACE
SOUTHINGTON CT
06489
US

V. Phone/Fax

Practice location:
  • Phone: 860-665-7813
  • Fax:
Mailing address:
  • Phone: 860-801-3158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8574
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: