Provider Demographics
NPI:1760821862
Name:DAMARLA, ANIL
Entity Type:Individual
Prefix:
First Name:ANIL
Middle Name:
Last Name:DAMARLA
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 1:31433 HARLO DR
Mailing Address - Street 2:APT D
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1985
Mailing Address - Country:US
Mailing Address - Phone:989-971-7775
Mailing Address - Fax:
Practice Address - Street 1:1525 W CARO RD
Practice Address - Street 2:CARO DRUGS
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-9686
Practice Address - Country:US
Practice Address - Phone:989-672-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040107183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist