Provider Demographics
NPI:1912213950
Name:KURUVILLA, IDA J (BS)
Entity Type:Individual
Prefix:MRS
First Name:IDA
Middle Name:J
Last Name:KURUVILLA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3716
Mailing Address - Country:US
Mailing Address - Phone:410-766-5220
Mailing Address - Fax:410-760-3634
Practice Address - Street 1:7501 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3716
Practice Address - Country:US
Practice Address - Phone:410-766-5220
Practice Address - Fax:410-760-3634
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11127183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist