Provider Demographics
NPI:1225536360
Name:CHENNAMANENI, RADHIKA
Entity Type:Individual
Prefix:
First Name:RADHIKA
Middle Name:
Last Name:CHENNAMANENI
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 1:45 RUGBY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-4268
Mailing Address - Country:US
Mailing Address - Phone:413-230-0124
Mailing Address - Fax:
Practice Address - Street 1:495 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3601
Practice Address - Country:US
Practice Address - Phone:860-953-0725
Practice Address - Fax:860-953-0822
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0011783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist