Provider Demographics
NPI:1720952989
Name:LUDOLPH, COLE
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:LUDOLPH
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 1:401 S OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-9013
Mailing Address - Country:US
Mailing Address - Phone:309-444-8897
Mailing Address - Fax:
Practice Address - Street 1:1101 PEORIA ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2350
Practice Address - Country:US
Practice Address - Phone:309-444-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049317949183700000X
IL051307291183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No183700000XPharmacy Service ProvidersPharmacy Technician