Provider Demographics
NPI:1598087272
Name:PAMIDIMUKKALA, VIJAY KUMAR
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:KUMAR
Last Name:PAMIDIMUKKALA
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 1:3 PENROSE CT
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1618
Mailing Address - Country:US
Mailing Address - Phone:732-499-0179
Mailing Address - Fax:
Practice Address - Street 1:4318 13TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-1338
Practice Address - Country:US
Practice Address - Phone:718-686-0047
Practice Address - Fax:718-686-0166
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032243183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist