Provider Demographics
NPI:1104366962
Name:RULLODA, MARLANE
Entity Type:Individual
Prefix:
First Name:MARLANE
Middle Name:
Last Name:RULLODA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13458 GRANITE PEAK LN
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-9537
Mailing Address - Country:US
Mailing Address - Phone:760-954-8390
Mailing Address - Fax:
Practice Address - Street 1:14011 PARK AVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2413
Practice Address - Country:US
Practice Address - Phone:760-843-2015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56909183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist