Healthcare Provider Details

I. General information

NPI: 1780115063
Provider Name (Legal Business Name): KRISHNA KANDAGATLA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 W HOLMES RD STE 23
LANSING MI
48910-0333
US

IV. Provider business mailing address

1122 W HOLMES RD STE 23
LANSING MI
48910-0333
US

V. Phone/Fax

Practice location:
  • Phone: 517-574-5015
  • Fax: 517-574-5362
Mailing address:
  • Phone: 517-574-5015
  • Fax: 517-574-5362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302035190
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: