Provider Demographics
NPI:1093329195
Name:MANAVALAN, DIVYA M
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:M
Last Name:MANAVALAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13503 WILD LILAC CT
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-3754
Mailing Address - Country:US
Mailing Address - Phone:832-577-0831
Mailing Address - Fax:
Practice Address - Street 1:2619 RED BLUFF RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77506-5270
Practice Address - Country:US
Practice Address - Phone:713-475-0939
Practice Address - Fax:713-477-8514
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX556601835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist