Healthcare Provider Details

I. General information

NPI: 1548568199
Provider Name (Legal Business Name): MUKUR GUPTA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8841 SIX FORKS RD
RALEIGH NC
27615-2970
US

IV. Provider business mailing address

712 UNISON CT
CARY NC
27519-5563
US

V. Phone/Fax

Practice location:
  • Phone: 919-847-8663
  • Fax:
Mailing address:
  • Phone: 919-267-6037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number20763
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: