Provider Demographics
NPI:1336710045
Name:RAGUPATHY, MAHENDRA
Entity Type:Individual
Prefix:
First Name:MAHENDRA
Middle Name:
Last Name:RAGUPATHY
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 1:1893 SHEPHERDS DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-5405
Mailing Address - Country:US
Mailing Address - Phone:248-854-1724
Mailing Address - Fax:
Practice Address - Street 1:560 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-1930
Practice Address - Country:US
Practice Address - Phone:248-430-8775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-03
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036820183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist