Provider Demographics
NPI:1265063143
Name:KOLLURI, RAVI KUMAR (RPH)
Entity type:Individual
Prefix:
First Name:RAVI
Middle Name:KUMAR
Last Name:KOLLURI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 ROSWELL RD STE 2140
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-3840
Mailing Address - Country:US
Mailing Address - Phone:770-321-1088
Mailing Address - Fax:
Practice Address - Street 1:2753 STONE HALL DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5061
Practice Address - Country:US
Practice Address - Phone:540-892-4635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0254341835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist