Provider Demographics
NPI:1285757088
Name:DUDHARA, KETAN (R PH)
Entity type:Individual
Prefix:
First Name:KETAN
Middle Name:
Last Name:DUDHARA
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41468 W VILLAGE GREEN BLVD APT 201
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3866
Mailing Address - Country:US
Mailing Address - Phone:734-844-1528
Mailing Address - Fax:
Practice Address - Street 1:1970 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2297
Practice Address - Country:US
Practice Address - Phone:313-386-6330
Practice Address - Fax:313-381-4801
Is Sole Proprietor?:No
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist