Provider Demographics
NPI:1770304917
Name:NAGARAJA, KIRAN
Entity type:Individual
Prefix:MR
First Name:KIRAN
Middle Name:
Last Name:NAGARAJA
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 1:24046 CLINTON KEITH RD STE 107
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-8060
Mailing Address - Country:US
Mailing Address - Phone:951-677-4880
Mailing Address - Fax:
Practice Address - Street 1:24046 CLINTON KEITH RD STE 107
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-8060
Practice Address - Country:US
Practice Address - Phone:951-677-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist