Healthcare Provider Details

I. General information

NPI: 1578797528
Provider Name (Legal Business Name): VENUGOPAL REDDY MAHESHWARAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 05/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E FRONT ST
BUCHANAN MI
49107-1458
US

IV. Provider business mailing address

5817 SHAWNEE CT APT# 2B
MISHAWAKA IN
46545-0917
US

V. Phone/Fax

Practice location:
  • Phone: 269-695-2000
  • Fax:
Mailing address:
  • Phone: 248-974-4985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302037533
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: