Provider Demographics
NPI:1992579700
Name:KOPPUZHAYIL, ROSHAN GEORGE
Entity type:Individual
Prefix:
First Name:ROSHAN
Middle Name:GEORGE
Last Name:KOPPUZHAYIL
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 1:3910 SAWYER BEND LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-7122
Mailing Address - Country:US
Mailing Address - Phone:832-495-5597
Mailing Address - Fax:
Practice Address - Street 1:6128 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77551-1030
Practice Address - Country:US
Practice Address - Phone:409-740-0876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty