Provider Demographics
NPI:1205117033
Name:TUDTUD, KELLY (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:TUDTUD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1551
Mailing Address - Country:US
Mailing Address - Phone:847-265-9641
Mailing Address - Fax:847-265-9739
Practice Address - Street 1:7501 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1551
Practice Address - Country:US
Practice Address - Phone:847-265-9641
Practice Address - Fax:847-265-9739
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051289018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362127039097Medicaid