Provider Demographics
NPI:1447671052
Name:RUDOLPH, JACQUELYN KATHLEEN (PHARM D)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:KATHLEEN
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:MS
Other - First Name:JACQUELYN
Other - Middle Name:KATHLEEN
Other - Last Name:BOGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:1010 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2902
Mailing Address - Country:US
Mailing Address - Phone:573-218-6754
Mailing Address - Fax:573-218-6762
Practice Address - Street 1:1010 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2902
Practice Address - Country:US
Practice Address - Phone:573-218-6754
Practice Address - Fax:573-218-6762
Is Sole Proprietor?:No
Enumeration Date:2013-12-27
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012025389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist