Provider Demographics
NPI:1740566405
Name:KODURI, JYOTHI
Entity Type:Individual
Prefix:
First Name:JYOTHI
Middle Name:
Last Name:KODURI
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JYOTHI
Other - Middle Name:
Other - Last Name:KODURI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:APPIKATLA VILLAGE
Mailing Address - Street 2:GUNTUR DISTRICT. ANDHRA PRUDISH STATR
Mailing Address - City:APPIKATLA
Mailing Address - State:BAPATLA
Mailing Address - Zip Code:50001
Mailing Address - Country:IN
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1233 PRECINCT LINE RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-4226
Practice Address - Country:US
Practice Address - Phone:817-595-2484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX46673OtherPHARMACIST LICENSE TEXAS