Provider Demographics
NPI:1033573852
Name:KUNTHIPURAM, BHASHYAM
Entity Type:Individual
Prefix:
First Name:BHASHYAM
Middle Name:
Last Name:KUNTHIPURAM
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 1:69 CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-2719
Mailing Address - Country:US
Mailing Address - Phone:516-333-0669
Mailing Address - Fax:
Practice Address - Street 1:556 GRAND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4386
Practice Address - Country:US
Practice Address - Phone:718-384-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist