Provider Demographics
NPI:1346580966
Name:NURU, ELIAS WASSIE (RPH)
Entity type:Individual
Prefix:
First Name:ELIAS
Middle Name:WASSIE
Last Name:NURU
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 BUSH ST
Mailing Address - Street 2:#4
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-3878
Mailing Address - Country:US
Mailing Address - Phone:408-482-5562
Mailing Address - Fax:
Practice Address - Street 1:845 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-3915
Practice Address - Country:US
Practice Address - Phone:707-459-5862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68484183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist