Provider Demographics
NPI:1376024208
Name:KANDALAI, LAXMI
Entity Type:Individual
Prefix:
First Name:LAXMI
Middle Name:
Last Name:KANDALAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3853
Mailing Address - Country:US
Mailing Address - Phone:973-865-7734
Mailing Address - Fax:
Practice Address - Street 1:31-00 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3963
Practice Address - Country:US
Practice Address - Phone:201-693-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02388200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist