Provider Demographics
NPI:1063122489
Name:KRISHNAPPA, MANJUNATH MEDAHALLI
Entity type:Individual
Prefix:
First Name:MANJUNATH
Middle Name:MEDAHALLI
Last Name:KRISHNAPPA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 EASTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2509
Mailing Address - Country:US
Mailing Address - Phone:410-790-8914
Mailing Address - Fax:
Practice Address - Street 1:75 N EAST PLZ
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-3617
Practice Address - Country:US
Practice Address - Phone:410-287-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist