Provider Demographics
NPI:1194000448
Name:VANGANUR, KRISHNA
Entity Type:Individual
Prefix:MR
First Name:KRISHNA
Middle Name:
Last Name:VANGANUR
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 1:4278 SHARON AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9G2X8
Mailing Address - Country:CA
Mailing Address - Phone:519-948-7375
Mailing Address - Fax:
Practice Address - Street 1:1045 S GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-3501
Practice Address - Country:US
Practice Address - Phone:586-954-4905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist