Provider Demographics
NPI:1902021876
Name:NOLASCO, RUDY JR
Entity Type:Individual
Prefix:MR
First Name:RUDY
Middle Name:
Last Name:NOLASCO
Suffix:JR
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 2797
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-2797
Mailing Address - Country:US
Mailing Address - Phone:505-425-8962
Mailing Address - Fax:
Practice Address - Street 1:602 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4248
Practice Address - Country:US
Practice Address - Phone:505-425-6241
Practice Address - Fax:505-425-8510
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist