Provider Demographics
NPI:1336362102
Name:MALLA, APPARAO
Entity Type:Individual
Prefix:
First Name:APPARAO
Middle Name:
Last Name:MALLA
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 1:217 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-4019
Mailing Address - Country:US
Mailing Address - Phone:845-634-6257
Mailing Address - Fax:718-933-6677
Practice Address - Street 1:58 E KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-7504
Practice Address - Country:US
Practice Address - Phone:718-584-8371
Practice Address - Fax:718-933-6677
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist