Healthcare Provider Details

I. General information

NPI: 1326329640
Provider Name (Legal Business Name): MARC JOHN KUDZOL RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 08/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 DUNLAWTON AVE
PORT ORANGE FL
32127-4754
US

IV. Provider business mailing address

1650 DUNLAWTON AVE
PORT ORANGE FL
32127-4754
US

V. Phone/Fax

Practice location:
  • Phone: 386-322-3267
  • Fax: 386-322-9321
Mailing address:
  • Phone: 386-322-3267
  • Fax: 386-322-9321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS0020054
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: