Provider Demographics
NPI:1275139396
Name:RAJU, ANU CHETTICHERIL
Entity Type:Individual
Prefix:
First Name:ANU
Middle Name:CHETTICHERIL
Last Name:RAJU
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 1:2808 VINTAGE VIEW LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4064
Mailing Address - Country:US
Mailing Address - Phone:863-529-1863
Mailing Address - Fax:863-678-1353
Practice Address - Street 1:500 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4901
Practice Address - Country:US
Practice Address - Phone:863-676-2564
Practice Address - Fax:863-678-1353
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43535183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist