Provider Demographics
NPI:1629401542
Name:JOHN, DETTY PALLIKKUNEAL
Entity Type:Individual
Prefix:
First Name:DETTY
Middle Name:PALLIKKUNEAL
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 STATE HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-2913
Mailing Address - Country:US
Mailing Address - Phone:469-287-0346
Mailing Address - Fax:
Practice Address - Street 1:4760 STATE HIGHWAY 121
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056-2913
Practice Address - Country:US
Practice Address - Phone:469-287-0346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist