Provider Demographics
NPI:1578667523
Name:YASHODA INC
Entity Type:Organization
Organization Name:YASHODA INC
Other - Org Name:MOORES LAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:VENKATA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUDUNURI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:302-697-0200
Mailing Address - Street 1:18 W LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-6248
Mailing Address - Country:US
Mailing Address - Phone:302-697-0200
Mailing Address - Fax:302-697-8205
Practice Address - Street 1:18 W LEBANON RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6248
Practice Address - Country:US
Practice Address - Phone:302-697-0200
Practice Address - Fax:302-697-8205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
DEA300009373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000038163Medicaid
0802327OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5599000001Medicare NSC