Provider Demographics
NPI:1922381342
Name:KODUMURU, PULLAIAH
Entity Type:Individual
Prefix:
First Name:PULLAIAH
Middle Name:
Last Name:KODUMURU
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 1:1201 SW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-2401
Mailing Address - Country:US
Mailing Address - Phone:786-597-2829
Mailing Address - Fax:305-324-8408
Practice Address - Street 1:1201 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2401
Practice Address - Country:US
Practice Address - Phone:305-324-8193
Practice Address - Fax:305-324-8408
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41125183500000X
NJ28RI03350400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist