Provider Demographics
NPI:1629504881
Name:SURAPANENI, KRISHNA
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:
Last Name:SURAPANENI
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 1:747 IRVINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040
Mailing Address - Country:US
Mailing Address - Phone:973-762-2700
Mailing Address - Fax:
Practice Address - Street 1:747 IRVINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040
Practice Address - Country:US
Practice Address - Phone:973-762-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03202500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist