Basic Information
| Provider Information | |||||||||
| NPI: | 1376147124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDOLPH | ||||||||
| FirstName: | VIOLA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 520 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286844380 | ||||||||
| FaxNumber: | 9282317938 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286844380 | ||||||||
| FaxNumber: | 9286845499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2020 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | S024089 | AZ | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.