Provider Demographics
NPI:1023438843
Name:KASISOMAYAJULA, KALYANI (RPH)
Entity type:Individual
Prefix:
First Name:KALYANI
Middle Name:
Last Name:KASISOMAYAJULA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 WICKHAM PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-9235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1844 WICKHAM PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-9235
Practice Address - Country:US
Practice Address - Phone:540-886-2076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-19
Last Update Date:2014-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist