Provider Demographics
NPI:1528242716
Name:LICUL, RUDY (RPH)
Entity type:Individual
Prefix:MR
First Name:RUDY
Middle Name:
Last Name:LICUL
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 1:15129 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3718
Mailing Address - Country:US
Mailing Address - Phone:718-762-3109
Mailing Address - Fax:718-939-2984
Practice Address - Street 1:1516 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-2907
Practice Address - Country:US
Practice Address - Phone:718-861-2359
Practice Address - Fax:718-939-2984
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040314-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist