Provider Demographics
NPI:1205092913
Name:BODDULURI, VENKATA GANGADHAR
Entity type:Individual
Prefix:
First Name:VENKATA
Middle Name:GANGADHAR
Last Name:BODDULURI
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 1:1072 SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-1766
Mailing Address - Country:US
Mailing Address - Phone:910-484-0159
Mailing Address - Fax:910-484-3270
Practice Address - Street 1:1072 SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-1766
Practice Address - Country:US
Practice Address - Phone:910-484-0159
Practice Address - Fax:910-484-3270
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist