Healthcare Provider Details

I. General information

NPI: 1639381411
Provider Name (Legal Business Name): JUDE STEPHEN VAVALA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 RAILROAD ST
SAINT MARYS PA
15857-1729
US

IV. Provider business mailing address

221 W THERESIA RD
SAINT MARYS PA
15857-2623
US

V. Phone/Fax

Practice location:
  • Phone: 814-834-3017
  • Fax:
Mailing address:
  • Phone: 814-781-1452
  • Fax: 814-834-1031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP027024L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: