Provider Demographics
NPI:1477143691
Name:LETELLIER, RUDY
Entity Type:Individual
Prefix:MR
First Name:RUDY
Middle Name:
Last Name:LETELLIER
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:PO BOX 3867
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39521-3867
Mailing Address - Country:US
Mailing Address - Phone:228-493-1055
Mailing Address - Fax:228-463-0117
Practice Address - Street 1:112 AUDERER BLVD
Practice Address - Street 2:
Practice Address - City:WAVELAND
Practice Address - State:MS
Practice Address - Zip Code:39576-2432
Practice Address - Country:US
Practice Address - Phone:228-463-1055
Practice Address - Fax:228-463-0117
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-07445183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist