Provider Demographics
NPI:1255684643
Name:PUDOTA, BALAMATHEW R
Entity Type:Individual
Prefix:
First Name:BALAMATHEW
Middle Name:R
Last Name:PUDOTA
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 1:2160 E HILL RD
Mailing Address - Street 2:APT #41
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5183
Mailing Address - Country:US
Mailing Address - Phone:810-919-8567
Mailing Address - Fax:
Practice Address - Street 1:502 S BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3640
Practice Address - Country:US
Practice Address - Phone:810-424-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist