Provider Demographics
NPI:1588216113
Name:PIDAKALA, DEEPTI (PHARMD)
Entity Type:Individual
Prefix:
First Name:DEEPTI
Middle Name:
Last Name:PIDAKALA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 CLYDE EDGERTON DR
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7972
Mailing Address - Country:US
Mailing Address - Phone:336-793-7052
Mailing Address - Fax:
Practice Address - Street 1:5322 US HIGHWAY 158
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-6907
Practice Address - Country:US
Practice Address - Phone:336-940-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-13
Last Update Date:2019-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28172183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist