Healthcare Provider Details

I. General information

NPI: 1255422911
Provider Name (Legal Business Name): VINDA JANARDAN KUDCHADKAR RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 SOUTHHAVEN AVE
MEDFORD NY
11763
US

IV. Provider business mailing address

76 SOUTHHAVEN AVE
MEDFORD NY
11763
US

V. Phone/Fax

Practice location:
  • Phone: 631-289-6888
  • Fax: 631-289-0208
Mailing address:
  • Phone: 631-289-6888
  • Fax: 631-289-0208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number030519
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: