Provider Demographics
NPI:1760142624
Name:PULI, SURENDRA K
Entity Type:Individual
Prefix:
First Name:SURENDRA
Middle Name:K
Last Name:PULI
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 1:3033 GODWIN TER APT 2H
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-5343
Mailing Address - Country:US
Mailing Address - Phone:214-909-9184
Mailing Address - Fax:
Practice Address - Street 1:SOUTH BRONX PHARMACY
Practice Address - Street 2:411 E 138TH ST
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454
Practice Address - Country:US
Practice Address - Phone:718-401-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI060008-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty