Provider Demographics
NPI:1346524030
Name:BAVADA, RAJENDRA D (RPH)
Entity Type:Individual
Prefix:MR
First Name:RAJENDRA
Middle Name:D
Last Name:BAVADA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 PENNCROSS DR SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9041
Mailing Address - Country:US
Mailing Address - Phone:616-554-9409
Mailing Address - Fax:
Practice Address - Street 1:6127 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7019
Practice Address - Country:US
Practice Address - Phone:616-696-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist