Healthcare Provider Details

I. General information

NPI: 1407545403
Provider Name (Legal Business Name): PUSHPA RANI MOHAPATRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 JACKSON AVE
ANN ARBOR MI
48103-3820
US

IV. Provider business mailing address

45519 MUIRFIELD DR
CANTON MI
48188-1098
US

V. Phone/Fax

Practice location:
  • Phone: 734-663-1362
  • Fax:
Mailing address:
  • Phone: 734-394-8084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303031029
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: