Provider Demographics
NPI:1679338586
Name:POTHULA, ASHOK
Entity Type:Individual
Prefix:
First Name:ASHOK
Middle Name:
Last Name:POTHULA
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 1:717 ENCINO PL NE STE 1
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2621
Mailing Address - Country:US
Mailing Address - Phone:505-243-3777
Mailing Address - Fax:505-212-0888
Practice Address - Street 1:717 ENCINO PL NE STE 1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2621
Practice Address - Country:US
Practice Address - Phone:505-243-3777
Practice Address - Fax:505-212-0888
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP000084731835C0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0207XPharmacy Service ProvidersPharmacistCompounded Sterile Preparations