=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326291006
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. DILEEP KUMAR POTNURI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2008
-----------------------------------------------------
Last Update Date | 07/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 E LITTLE CREEK RD
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23518-3710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-781-8992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 N MAIN ST
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-539-9992
-----------------------------------------------------
Fax | 757-539-0810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202207245
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------