Healthcare Provider Details

I. General information

NPI: 1912507146
Provider Name (Legal Business Name): PRASHANTHI KOWKUTLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W PIPELINE RD
HURST TX
76053-4928
US

IV. Provider business mailing address

8725 HAVANT LN
PLANO TX
75024-7288
US

V. Phone/Fax

Practice location:
  • Phone: 817-199-3525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number44905
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: