MEDICARE: MR. VENKATA S VALLABHANENI PHARMACIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302035145	MI

General Provider Information

NPI Number	:	1871876052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VENKATA S VALLABHANENI PHARMACIST

Provider Business Mailing Address
First Line	:	46253 PINEHURST DR
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48168
Country	:	US
Telephone Number	:	248-835-8085
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 S OLD US 23
Second Line	:
City	:	BRIGHTON
State	:	MI
Zip	:	48116
Country	:	US
Telephone Number	:	810-229-5466
Fax Number	:	810-229-5593

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2011
Last Update Date	:	09/23/2011

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