Healthcare Provider Details

I. General information

NPI: 1578706511
Provider Name (Legal Business Name): RAGHUVARDHAN REDDY GUNUKULA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32983 RYAN RD
WARREN MI
48092-4353
US

IV. Provider business mailing address

44310 PINE DR
STERLING HEIGHTS MI
48313-1247
US

V. Phone/Fax

Practice location:
  • Phone: 586-264-2724
  • Fax:
Mailing address:
  • Phone: 586-873-2476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302036561
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: