Provider Demographics
NPI:1497818165
Name:RAGHUNANDAN, LATCHMAN (BS)
Entity Type:Individual
Prefix:MR
First Name:LATCHMAN
Middle Name:
Last Name:RAGHUNANDAN
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 AVON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-2531
Mailing Address - Country:US
Mailing Address - Phone:973-824-5010
Mailing Address - Fax:973-824-5920
Practice Address - Street 1:125 AVON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108-2531
Practice Address - Country:US
Practice Address - Phone:973-824-5010
Practice Address - Fax:973-824-5920
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRI20923183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7946007Medicaid