=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902484439
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN RUDOFKER RUDIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2021
-----------------------------------------------------
Last Update Date | 03/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 960 WYOMING AVE
-----------------------------------------------------
City | EXETER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18643-1199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-654-7422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 SALEM DR
-----------------------------------------------------
City | WILKES BARRE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18702-7323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-817-3040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP033853L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------