Provider Demographics
NPI:1710042551
Name:JUDD, JERRY DENNIS (R PH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:DENNIS
Last Name:JUDD
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 U FORBES WAY
Mailing Address - Street 2:
Mailing Address - City:FLEMINGSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41041-7284
Mailing Address - Country:US
Mailing Address - Phone:606-845-4199
Mailing Address - Fax:
Practice Address - Street 1:55 FOUNDATION DR
Practice Address - Street 2:
Practice Address - City:FLEMINGSBURG
Practice Address - State:KY
Practice Address - Zip Code:41041-9815
Practice Address - Country:US
Practice Address - Phone:606-849-5077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007281183500000X
WVRP0004521183500000X
SC007544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist