Provider Demographics
NPI:1265760011
Name:KUPPUSAMY, PRATIKSHA (RPH)
Entity type:Individual
Prefix:
First Name:PRATIKSHA
Middle Name:
Last Name:KUPPUSAMY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 MILAGRO DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78733-5754
Mailing Address - Country:US
Mailing Address - Phone:914-882-3706
Mailing Address - Fax:
Practice Address - Street 1:2401 RANCH ROAD 620 S
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78738-5603
Practice Address - Country:US
Practice Address - Phone:512-236-7887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44250183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist