Provider Demographics
NPI:1710264551
Name:VAVILALA, RAJENDRA PRASAD (RPH)
Entity Type:Individual
Prefix:MR
First Name:RAJENDRA PRASAD
Middle Name:
Last Name:VAVILALA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21530 GREEN HILL RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-4447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20770 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-3018
Practice Address - Country:US
Practice Address - Phone:248-548-9935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302037903Medicaid