Healthcare Provider Details

I. General information

NPI: 1851743256
Provider Name (Legal Business Name): RAJA IDUPULAPATI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 EXECUTIVE DR
SHELBURNE VT
05482-7142
US

IV. Provider business mailing address

388 SHELBURNE RD APT 102
BURLINGTON VT
05401-6946
US

V. Phone/Fax

Practice location:
  • Phone: 802-985-0008
  • Fax: 802-985-0011
Mailing address:
  • Phone: 802-985-0008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number033.0003804
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: