Provider Demographics
NPI:1407545403
Name:MOHAPATRA, PUSHPA RANI
Entity Type:Individual
Prefix:
First Name:PUSHPA
Middle Name:RANI
Last Name:MOHAPATRA
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 1:45519 MUIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1098
Mailing Address - Country:US
Mailing Address - Phone:734-394-8084
Mailing Address - Fax:
Practice Address - Street 1:2603 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3820
Practice Address - Country:US
Practice Address - Phone:734-663-1362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303031029183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician