Healthcare Provider Details

I. General information

NPI: 1467766519
Provider Name (Legal Business Name): CARLENE MARIE KUDRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2010
Last Update Date: 07/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 N PROSPECT AVE
CHAMPAIGN IL
61822-1231
US

IV. Provider business mailing address

2102 N PROSPECT AVE
CHAMPAIGN IL
61822-1231
US

V. Phone/Fax

Practice location:
  • Phone: 217-355-3345
  • Fax: 217-355-3345
Mailing address:
  • Phone: 217-355-3345
  • Fax: 217-355-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number51036228
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: