Provider Demographics
NPI:1912375833
Name:MODI, VASUNDHARA
Entity Type:Individual
Prefix:
First Name:VASUNDHARA
Middle Name:
Last Name:MODI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8110
Mailing Address - Country:US
Mailing Address - Phone:928-344-2341
Mailing Address - Fax:928-344-5252
Practice Address - Street 1:2800 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8110
Practice Address - Country:US
Practice Address - Phone:928-344-2341
Practice Address - Fax:928-344-5252
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020279183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist