Provider Demographics
NPI:1376772129
Name:PUTHENTHARAYIL, CHACKO JOSEPH (BPHARM)
Entity Type:Individual
Prefix:MR
First Name:CHACKO
Middle Name:JOSEPH
Last Name:PUTHENTHARAYIL
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 1:56507 KEN CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-6108
Mailing Address - Country:US
Mailing Address - Phone:489-467-7252
Mailing Address - Fax:
Practice Address - Street 1:116 N. MAIN STREET
Practice Address - Street 2:OLIVET PHARMACY
Practice Address - City:OLIVET
Practice Address - State:MI
Practice Address - Zip Code:49076
Practice Address - Country:US
Practice Address - Phone:692-805-0052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302035928OtherPHARMACIST