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General NPI Number Information
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NPI Number | 1275139396
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Entity Type | Individual
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Provider Name | ANU CHETTICHERIL RAJU
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Gender | Male
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Dates
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Enumeration Date | 12/05/2020
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Last Update Date | 12/05/2020
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Provider Practice Location Address
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Address Line | 500 S 11TH ST
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City | LAKE WALES
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State | FL
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Zip | 33853-4901
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Country | US
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Telephone | 863-676-2564
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Fax | 863-678-1353
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Provider Business Mailing Address
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Address Line | 2808 VINTAGE VIEW LOOP
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City | LAKELAND
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State | FL
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Zip | 33812-4064
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Country | US
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Telephone | 863-529-1863
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Fax | 863-678-1353
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PS43535
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License Number State | FL
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