Provider Demographics
NPI:1073927406
Name:UDVADIA, MUKUND
Entity Type:Individual
Prefix:
First Name:MUKUND
Middle Name:
Last Name:UDVADIA
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 1:2195 PARLIAMENT DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6024
Mailing Address - Country:US
Mailing Address - Phone:404-933-1221
Mailing Address - Fax:
Practice Address - Street 1:440 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7341
Practice Address - Country:US
Practice Address - Phone:770-506-0677
Practice Address - Fax:770-507-5963
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH-026770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist