Provider Demographics
NPI:1629391578
Name:HUDAK, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HUDAK
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 1:14768 FIRESIDE CIR
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:MN
Mailing Address - Zip Code:56320-9757
Mailing Address - Country:US
Mailing Address - Phone:320-333-3805
Mailing Address - Fax:
Practice Address - Street 1:14768 FIRESIDE CIR
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:MN
Practice Address - Zip Code:56320-9757
Practice Address - Country:US
Practice Address - Phone:320-333-3805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-07
Last Update Date:2010-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119547183500000X
MEPR4019183500000X
NJ28RI01765800183500000X
NY039318-1183500000X
PAPR036359R183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist