Healthcare Provider Details

I. General information

NPI: 1932447257
Provider Name (Legal Business Name): RAVIKIRAN NALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2013
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4495 LINCOLN WAY W
SAINT THOMAS PA
17252-9679
US

IV. Provider business mailing address

4495 LINCOLN WAY W
SAINT THOMAS PA
17252-9679
US

V. Phone/Fax

Practice location:
  • Phone: 717-369-4636
  • Fax:
Mailing address:
  • Phone: 201-284-9281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03545900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP448538
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: