Provider Demographics
NPI:1699205138
Name:RUDOLPH, CHAD M (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:M
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:DR
Other - First Name:CHAD
Other - Middle Name:M
Other - Last Name:RUDOLPH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:1705 CAITLIN CT
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-4055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-5936
Practice Address - Country:US
Practice Address - Phone:504-252-9686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17966183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist