Provider Demographics
NPI:1528399490
Name:VENNAM, VIJAY
Entity Type:Individual
Prefix:MR
First Name:VIJAY
Middle Name:
Last Name:VENNAM
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 1:2801 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8125
Mailing Address - Country:US
Mailing Address - Phone:928-344-1010
Mailing Address - Fax:
Practice Address - Street 1:2801 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8125
Practice Address - Country:US
Practice Address - Phone:928-344-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS017009183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD05868094OtherDRIVERS LICENCE