Provider Demographics
NPI:1386887107
Name:POLISETTI, SURYAKUMARI
Entity type:Individual
Prefix:
First Name:SURYAKUMARI
Middle Name:
Last Name:POLISETTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N SQUIRREL RD
Mailing Address - Street 2:APT#901
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-4015
Mailing Address - Country:US
Mailing Address - Phone:517-402-7420
Mailing Address - Fax:248-625-1354
Practice Address - Street 1:5751 CLARKSTON RD
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-4707
Practice Address - Country:US
Practice Address - Phone:248-625-1015
Practice Address - Fax:248-625-1354
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist