Provider Demographics
NPI:1215212071
Name:PANDA, ACHINTA KUMAR
Entity Type:Individual
Prefix:
First Name:ACHINTA
Middle Name:KUMAR
Last Name:PANDA
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 1:8035 HIDDEN PONDS DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7230
Mailing Address - Country:US
Mailing Address - Phone:914-433-3586
Mailing Address - Fax:
Practice Address - Street 1:1570 E PIERSON RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-1817
Practice Address - Country:US
Practice Address - Phone:810-659-0244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist