MEDICARE: MR. MORRIE RUDBERG RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	7021	WI

General Provider Information

NPI Number	:	1184841264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MORRIE RUDBERG RPH

Provider Business Mailing Address
First Line	:	4323 N WILDWOOD AVE
Second Line	:
City	:	SHOREWOOD
State	:	WI
Zip	:	53211-1437
Country	:	US
Telephone Number	:	414-962-6357
Fax Number	:

Provider Business Practice Location Address
First Line	:	9200 W WISCONSIN AVE
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-3522
Country	:	US
Telephone Number	:	414-805-6501
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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