Provider Demographics
NPI:1902189665
Name:AVANADULA, RAJA
Entity Type:Individual
Prefix:MR
First Name:RAJA
Middle Name:
Last Name:AVANADULA
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 1:2108 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-2628
Mailing Address - Country:US
Mailing Address - Phone:903-583-8017
Mailing Address - Fax:
Practice Address - Street 1:2108 N CENTER ST
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-2628
Practice Address - Country:US
Practice Address - Phone:903-583-8017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51172183500000X
KY013223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist