Provider Demographics
NPI:1003050113
Name:KOMIRISETTY, SURESH KUMAR
Entity Type:Individual
Prefix:MR
First Name:SURESH
Middle Name:KUMAR
Last Name:KOMIRISETTY
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 1:1795 NEMOKE CT
Mailing Address - Street 2:APARTMENT # 9
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-8679
Mailing Address - Country:US
Mailing Address - Phone:270-535-8708
Mailing Address - Fax:
Practice Address - Street 1:1705 W MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2660
Practice Address - Country:US
Practice Address - Phone:517-372-6700
Practice Address - Fax:517-372-0616
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist