Provider Demographics
NPI:1093038572
Name:RUDNER, MICHAEL (PH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:RUDNER
Suffix:
Gender:M
Credentials:PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 CLIFFSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3048
Mailing Address - Country:US
Mailing Address - Phone:516-791-6650
Mailing Address - Fax:
Practice Address - Street 1:2102 MOTT AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3302
Practice Address - Country:US
Practice Address - Phone:718-327-2559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27752183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist