Provider Demographics
NPI:1912067364
Name:JUDD, PHILLIP
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:JUDD
Suffix:
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 1:11121 N RODNEY PARHAM RD STE 42B
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-4108
Mailing Address - Country:US
Mailing Address - Phone:501-223-2636
Mailing Address - Fax:501-224-5253
Practice Address - Street 1:11121 N RODNEY PARHAM RD STE 42B
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-4108
Practice Address - Country:US
Practice Address - Phone:501-223-2636
Practice Address - Fax:501-224-5253
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR17560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1240630001Medicare NSC