Healthcare Provider Details

I. General information

NPI: 1699448548
Provider Name (Legal Business Name): KOUSALYA SELVAKUMAR DR.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KOUSALYA JAGANNATHAN DR.

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 RAEFORD RD
FAYETTEVILLE NC
28303-5433
US

IV. Provider business mailing address

804 KINGSWOOD DR
CARY NC
27513-4624
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-2170
  • Fax:
Mailing address:
  • Phone: 603-892-1579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number29340
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: