Provider Demographics
NPI:1700133766
Name:KODALI, VENKATA S (RPH)
Entity Type:Individual
Prefix:
First Name:VENKATA
Middle Name:S
Last Name:KODALI
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 1:345 SOMERSET ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07060-4774
Mailing Address - Country:US
Mailing Address - Phone:908-412-9400
Mailing Address - Fax:908-757-2228
Practice Address - Street 1:345 SOMERSET ST
Practice Address - Street 2:LAND MARK PHARMACY
Practice Address - City:NORTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-4774
Practice Address - Country:US
Practice Address - Phone:908-412-9400
Practice Address - Fax:908-757-2228
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02986900183500000X
NY20055536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist