Provider Demographics
NPI:1477954592
Name:PULICKAL, DEEPA
Entity Type:Individual
Prefix:
First Name:DEEPA
Middle Name:
Last Name:PULICKAL
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 1:8400 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-1468
Mailing Address - Country:US
Mailing Address - Phone:510-430-9723
Mailing Address - Fax:
Practice Address - Street 1:8400 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621-1468
Practice Address - Country:US
Practice Address - Phone:510-430-9723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH62407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist