Provider Demographics
NPI:1558066316
Name:KAMMULURI, RATNA KUMAR
Entity Type:Individual
Prefix:
First Name:RATNA KUMAR
Middle Name:
Last Name:KAMMULURI
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 1:39 BUCKLAND ST
Mailing Address - Street 2:APT 11133 BUILDING 11
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042
Mailing Address - Country:US
Mailing Address - Phone:860-709-4566
Mailing Address - Fax:
Practice Address - Street 1:149 DEMING ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-1731
Practice Address - Country:US
Practice Address - Phone:860-644-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11909183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist