Provider Demographics
NPI:1346842077
Name:KUKKILLAYA, JAYAKRISHNA UPPOOR (BPHARM)
Entity Type:Individual
Prefix:MR
First Name:JAYAKRISHNA
Middle Name:UPPOOR
Last Name:KUKKILLAYA
Suffix:
Gender:M
Credentials:BPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 MOUNTAINEER BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-9446
Mailing Address - Country:US
Mailing Address - Phone:304-766-1725
Mailing Address - Fax:304-746-1727
Practice Address - Street 1:2700 MOUNTAINEER BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-9446
Practice Address - Country:US
Practice Address - Phone:304-766-1725
Practice Address - Fax:304-746-1727
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist