Provider Demographics
NPI:1619254836
Name:MUDUSU, POORNA PRASAD REDDY
Entity Type:Individual
Prefix:
First Name:POORNA
Middle Name:PRASAD REDDY
Last Name:MUDUSU
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 1:4200 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-2619
Mailing Address - Country:US
Mailing Address - Phone:305-444-2544
Mailing Address - Fax:
Practice Address - Street 1:4200 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-2619
Practice Address - Country:US
Practice Address - Phone:305-444-2544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist