Healthcare Provider Details

I. General information

NPI: 1689553810
Provider Name (Legal Business Name): POOJA GUMUDAVELLI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2025
Last Update Date: 09/01/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 E 167TH ST
BRONX NY
10452-8203
US

IV. Provider business mailing address

30 KADY LN
KENDALL PARK NJ
08824-1471
US

V. Phone/Fax

Practice location:
  • Phone: 718-538-8100
  • Fax:
Mailing address:
  • Phone: 208-409-2615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number072976
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: