Healthcare Provider Details

I. General information

NPI: 1306570114
Provider Name (Legal Business Name): VISHAL KUKREJA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2022
Last Update Date: 07/16/2022
Certification Date: 07/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 N EMERSON AVE
GREENWOOD IN
46143-6275
US

IV. Provider business mailing address

567 LEGACY BLVD
GREENWOOD IN
46143-6427
US

V. Phone/Fax

Practice location:
  • Phone: 317-885-9059
  • Fax:
Mailing address:
  • Phone: 857-544-3272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number26023819A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: