Provider Demographics
NPI:1508014770
Name:PENUMETSA, BANGARRAJU
Entity Type:Individual
Prefix:MR
First Name:BANGARRAJU
Middle Name:
Last Name:PENUMETSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2512
Mailing Address - Country:US
Mailing Address - Phone:718-847-9850
Mailing Address - Fax:
Practice Address - Street 1:11901 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2512
Practice Address - Country:US
Practice Address - Phone:718-847-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049201183500000X
NJ28RI03182500183500000X
MI5302035241183500000X
MD16662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02646817Medicaid
NY02646817Medicaid