Provider Demographics
NPI:1841418126
Name:PENUMUDI, MALLIKAJRUNA RAO (MS)
Entity Type:Individual
Prefix:MR
First Name:MALLIKAJRUNA RAO
Middle Name:
Last Name:PENUMUDI
Suffix:
Gender:M
Credentials:MS
Other - Prefix:MR
Other - First Name:PENUMUDI
Other - Middle Name:
Other - Last Name:RAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:1508 TIPPERARY DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6034
Mailing Address - Country:US
Mailing Address - Phone:321-574-0457
Mailing Address - Fax:
Practice Address - Street 1:975 S BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1852
Practice Address - Country:US
Practice Address - Phone:321-723-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS40838183500000X
GARPH022513183500000X
MEPR5165183500000X
NH3383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist