Provider Demographics
NPI:1386193555
Name:SUREJA, PALAK (PHARMACIST)
Entity type:Individual
Prefix:
First Name:PALAK
Middle Name:
Last Name:SUREJA
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 CORUNNA RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4152
Mailing Address - Country:US
Mailing Address - Phone:810-733-3355
Mailing Address - Fax:
Practice Address - Street 1:4313 CORUNNA RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4152
Practice Address - Country:US
Practice Address - Phone:810-733-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist