Provider Demographics
NPI:1366673287
Name:ODAPALLY, LAVAN KUMAR (RPH)
Entity Type:Individual
Prefix:
First Name:LAVAN KUMAR
Middle Name:
Last Name:ODAPALLY
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 1:3130 STONEBRIDGE CT
Mailing Address - Street 2:11
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-8048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:MI
Practice Address - Zip Code:49057-1008
Practice Address - Country:US
Practice Address - Phone:269-621-3654
Practice Address - Fax:269-621-3534
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist