Provider Demographics
NPI:1669814976
Name:DHULIPALLA, PRAVEEN KUMAR
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:KUMAR
Last Name:DHULIPALLA
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 1:28 BUCKINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-5104
Mailing Address - Country:US
Mailing Address - Phone:203-567-0135
Mailing Address - Fax:
Practice Address - Street 1:28 BUCKINGHAM RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-5104
Practice Address - Country:US
Practice Address - Phone:203-567-0135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-28
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT0010979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7297420001Medicare NSC