Healthcare Provider Details

I. General information

NPI: 1467893719
Provider Name (Legal Business Name): MR. VAMSI KRISHNA GUDEY VENKATA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WASHINGTON ST
NEWARK NJ
07102-2921
US

IV. Provider business mailing address

200 WASHINGTON ST
NEWARK NJ
07102-2921
US

V. Phone/Fax

Practice location:
  • Phone: 973-623-5566
  • Fax: 973-623-7144
Mailing address:
  • Phone: 973-623-5566
  • Fax: 973-623-7144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number057961-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RI03400500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: