Provider Demographics
NPI:1104112903
Name:KNUDSEN, JUDD ALAN (RPH)
Entity type:Individual
Prefix:
First Name:JUDD
Middle Name:ALAN
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 N WHITLEY DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2129
Mailing Address - Country:US
Mailing Address - Phone:208-452-7075
Mailing Address - Fax:208-452-7446
Practice Address - Street 1:1620 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2129
Practice Address - Country:US
Practice Address - Phone:208-452-7075
Practice Address - Fax:208-452-7446
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15851183500000X
IDP6023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist