Provider Demographics
NPI:1306249222
Name:KOMARNENI, PRADEEP
Entity type:Individual
Prefix:
First Name:PRADEEP
Middle Name:
Last Name:KOMARNENI
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 1:6968 SW 39TH ST
Mailing Address - Street 2:301
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-2413
Mailing Address - Country:US
Mailing Address - Phone:646-438-2721
Mailing Address - Fax:
Practice Address - Street 1:6968 SW 39TH ST
Practice Address - Street 2:301
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-2413
Practice Address - Country:US
Practice Address - Phone:646-438-2721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57177183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888892OtherNABP