Provider Demographics
NPI:1033460563
Name:POTLURI, VENU GOPAL (RPH)
Entity Type:Individual
Prefix:
First Name:VENU
Middle Name:GOPAL
Last Name:POTLURI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1856 COOLIDGE HWY
Mailing Address - Street 2:APT 209
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3609
Mailing Address - Country:US
Mailing Address - Phone:248-792-9501
Mailing Address - Fax:
Practice Address - Street 1:1059 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-1855
Practice Address - Country:US
Practice Address - Phone:248-808-6929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist