Basic Information
| Provider Information | |||||||||
| NPI: | 1881197713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UDE | ||||||||
| FirstName: | UDE | ||||||||
| MiddleName: | UCHE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 118A EDNA | ||||||||
| Address2: | |||||||||
| City: | WAYNESVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655837875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146005329 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 118 EDNA | ||||||||
| Address2: | |||||||||
| City: | WAYNESVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655837875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146005329 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | 2013031924 | MO | Y |
ID Information
| ID | Type | State | Issuer | Description | 2013031924 | 01 | MO | STATE LICENSE | OTHER |