Provider Demographics
NPI:1477336808
Name:DELEON, RUDY
Entity Type:Individual
Prefix:
First Name:RUDY
Middle Name:
Last Name:DELEON
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 1:679 SUN TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-8934
Mailing Address - Country:US
Mailing Address - Phone:208-308-6992
Mailing Address - Fax:
Practice Address - Street 1:526 SHOUP AVE W STE K
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5050
Practice Address - Country:US
Practice Address - Phone:208-734-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist