Provider Demographics
NPI:1285117341
Name:KUDAYAH, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:KUDAYAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1850
Practice Address - Country:US
Practice Address - Phone:212-434-3226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04047-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist