Provider Demographics
NPI:1396003539
Name:RUDACK, MARVIN AARON (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:AARON
Last Name:RUDACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 W AUER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3133
Mailing Address - Country:US
Mailing Address - Phone:414-871-7695
Mailing Address - Fax:
Practice Address - Street 1:3512 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-2701
Practice Address - Country:US
Practice Address - Phone:414-332-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6890-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist