Provider Demographics
NPI:1669871422
Name:JUDA, DIANE (RPH)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JUDA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 SHADY PINE CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-8239
Mailing Address - Country:US
Mailing Address - Phone:410-340-7260
Mailing Address - Fax:
Practice Address - Street 1:1513 N HOWE ST
Practice Address - Street 2:SUITE 8
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-2769
Practice Address - Country:US
Practice Address - Phone:910-454-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist