Provider Demographics
NPI:1871060087
Name:WUDEL, KENNETH ALAN (PHARM D)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:WUDEL
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 APPLEWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242
Mailing Address - Country:US
Mailing Address - Phone:209-334-5499
Mailing Address - Fax:707-374-5408
Practice Address - Street 1:407 MAIN ST. DELTA PHARMACY
Practice Address - Street 2:
Practice Address - City:RIO VISTA
Practice Address - State:CA
Practice Address - Zip Code:94571
Practice Address - Country:US
Practice Address - Phone:707-374-5135
Practice Address - Fax:707-374-5408
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist