Healthcare Provider Details

I. General information

NPI: 1639223167
Provider Name (Legal Business Name): RUDY RAY SITES RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 ORCHARD ST
PIEDMONT WV
26750-1036
US

IV. Provider business mailing address

700 LOUGHS LN
KEYSER WV
26726-2204
US

V. Phone/Fax

Practice location:
  • Phone: 304-355-2700
  • Fax:
Mailing address:
  • Phone: 304-788-3828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2391
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: