Provider Demographics
NPI:1144566324
Name:PEDAVEETI, PRUDVI REDDY
Entity Type:Individual
Prefix:
First Name:PRUDVI
Middle Name:REDDY
Last Name:PEDAVEETI
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 1:4528 EDMONDSON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1506
Mailing Address - Country:US
Mailing Address - Phone:410-566-5565
Mailing Address - Fax:
Practice Address - Street 1:9155 BOURBON ST APT C
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-1647
Practice Address - Country:US
Practice Address - Phone:410-457-7725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist