Provider Demographics
NPI:1205152683
Name:VUTLA, NARENDRA B (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NARENDRA
Middle Name:B
Last Name:VUTLA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 N PLANK RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-2118
Mailing Address - Country:US
Mailing Address - Phone:845-561-3784
Mailing Address - Fax:845-561-2961
Practice Address - Street 1:39 N PLANK RD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-2118
Practice Address - Country:US
Practice Address - Phone:845-561-3784
Practice Address - Fax:845-561-2961
Is Sole Proprietor?:No
Enumeration Date:2010-04-11
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03187800183500000X
NY054451183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY054451OtherREGISTERED PHARMACIST
NY054451-IOtherIMMUNIZING PHARMACIST
NJ28RI03187800OtherPHARMACIST LICENSE