Provider Demographics
NPI:1255096095
Name:INDUPURU, VINOD KUMAR
Entity type:Individual
Prefix:MR
First Name:VINOD KUMAR
Middle Name:
Last Name:INDUPURU
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 1:42753 WILMAR SQ
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-4147
Mailing Address - Country:US
Mailing Address - Phone:703-300-7818
Mailing Address - Fax:
Practice Address - Street 1:9871 GEORGETOWN PIKE
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:VA
Practice Address - Zip Code:22066-2617
Practice Address - Country:US
Practice Address - Phone:703-759-2428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist