Provider Demographics
NPI:1265862122
Name:BRMAJJI, TAJU
Entity Type:Individual
Prefix:
First Name:TAJU
Middle Name:
Last Name:BRMAJJI
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 1:1540 28TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1412
Mailing Address - Country:US
Mailing Address - Phone:616-452-3142
Mailing Address - Fax:616-248-2662
Practice Address - Street 1:1540 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-1412
Practice Address - Country:US
Practice Address - Phone:616-452-3142
Practice Address - Fax:616-248-2662
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist