Provider Demographics
NPI:1487328654
Name:RUDOLPH, LINDSEY ANN
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:ANN
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 EAST MORRIS STREET
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257
Mailing Address - Country:US
Mailing Address - Phone:360-466-3124
Mailing Address - Fax:
Practice Address - Street 1:708 EAST MORRIS STREET
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257
Practice Address - Country:US
Practice Address - Phone:360-466-3124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61077394183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist