Provider Demographics
NPI:1538491352
Name:DANTULURI, MANDAKINI
Entity Type:Individual
Prefix:
First Name:MANDAKINI
Middle Name:
Last Name:DANTULURI
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 1:78 HANA RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2037
Mailing Address - Country:US
Mailing Address - Phone:732-570-9402
Mailing Address - Fax:
Practice Address - Street 1:1 MAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1001
Practice Address - Country:US
Practice Address - Phone:201-845-3287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03057400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist