Provider Demographics
NPI:1932447257
Name:NALLA, RAVIKIRAN
Entity type:Individual
Prefix:
First Name:RAVIKIRAN
Middle Name:
Last Name:NALLA
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 1:4495 LINCOLN WAY W
Mailing Address - Street 2:
Mailing Address - City:SAINT THOMAS
Mailing Address - State:PA
Mailing Address - Zip Code:17252-9679
Mailing Address - Country:US
Mailing Address - Phone:201-284-9281
Mailing Address - Fax:
Practice Address - Street 1:4495 LINCOLN WAY W
Practice Address - Street 2:
Practice Address - City:SAINT THOMAS
Practice Address - State:PA
Practice Address - Zip Code:17252-9679
Practice Address - Country:US
Practice Address - Phone:717-369-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-21
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03545900183500000X
PARP448538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist