Provider Demographics
NPI:1184933319
Name:REDDY, PRAVEEN P
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:P
Last Name:REDDY
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 1:1 MILLENIUM DR
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-1000
Mailing Address - Country:US
Mailing Address - Phone:609-880-2000
Mailing Address - Fax:
Practice Address - Street 1:1 MILLENIUM DR
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1000
Practice Address - Country:US
Practice Address - Phone:609-880-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2010-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03074100183500000X
NY050754183500000X
DEA10002833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist