Provider Demographics
NPI:1518656677
Name:MEDEPALLI, PREM KUMAR
Entity Type:Individual
Prefix:MR
First Name:PREM KUMAR
Middle Name:
Last Name:MEDEPALLI
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 1:903 ENGH RD STE # A, OMAK PHARMACY
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841
Mailing Address - Country:US
Mailing Address - Phone:509-322-6264
Mailing Address - Fax:
Practice Address - Street 1:OMAK PHARMACY
Practice Address - Street 2:903 ENGH RD STE # A,
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:509-422-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61230173183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist