=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275978397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOLLY ABRAHAM RAJU PHARM.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2013
-----------------------------------------------------
Last Update Date | 05/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5939 HARRY HINES BLVD POB II STE 600
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75235-6246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-645-5609
-----------------------------------------------------
Fax | 214-645-5688
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 S HAMPTON CT
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75056-5580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-899-0395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P1200X
-----------------------------------------------------
Taxonomy Name | Pharmacotherapy Pharmacist
-----------------------------------------------------
License Number | 42429
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------