Provider Demographics
NPI:1740873769
Name:KODAMBALLI, SHUBHA C
Entity type:Individual
Prefix:
First Name:SHUBHA
Middle Name:C
Last Name:KODAMBALLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-3441
Mailing Address - Country:US
Mailing Address - Phone:732-688-2369
Mailing Address - Fax:
Practice Address - Street 1:3191 STATE ROUTE 27
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:NJ
Practice Address - Zip Code:08823-1356
Practice Address - Country:US
Practice Address - Phone:732-798-6076
Practice Address - Fax:732-798-6078
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04163300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist