Provider Demographics
NPI:1619392784
Name:TALLURI, RAVIKUMAR
Entity Type:Individual
Prefix:
First Name:RAVIKUMAR
Middle Name:
Last Name:TALLURI
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 1:7126 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5415
Mailing Address - Country:US
Mailing Address - Phone:201-868-6900
Mailing Address - Fax:201-868-7127
Practice Address - Street 1:7126 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5415
Practice Address - Country:US
Practice Address - Phone:201-868-6900
Practice Address - Fax:201-868-7127
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03271800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist