Provider Demographics
NPI:1306570114
Name:KUKREJA, VISHAL
Entity type:Individual
Prefix:
First Name:VISHAL
Middle Name:
Last Name:KUKREJA
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 1:567 LEGACY BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-6427
Mailing Address - Country:US
Mailing Address - Phone:857-544-3272
Mailing Address - Fax:
Practice Address - Street 1:1133 N EMERSON AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-6275
Practice Address - Country:US
Practice Address - Phone:317-885-9059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023819A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26023819AOtherPHARMACIST LICENSE