Provider Demographics
NPI:1467762955
Name:MALLADI, VIDYA (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:
Last Name:MALLADI
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3548 E JUANITA AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2249
Mailing Address - Country:US
Mailing Address - Phone:480-813-4869
Mailing Address - Fax:
Practice Address - Street 1:2000 S MILL AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2128
Practice Address - Country:US
Practice Address - Phone:480-921-8013
Practice Address - Fax:480-921-7219
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS014741183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS014741OtherARIZONA PHARMACIST LICENSE