Provider Demographics
NPI:1780115063
Name:KANDAGATLA, KRISHNA (RPH)
Entity type:Individual
Prefix:
First Name:KRISHNA
Middle Name:
Last Name:KANDAGATLA
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 1:1122 W HOLMES RD STE 23
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-0333
Mailing Address - Country:US
Mailing Address - Phone:517-574-5015
Mailing Address - Fax:517-574-5362
Practice Address - Street 1:1122 W HOLMES RD STE 23
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-0333
Practice Address - Country:US
Practice Address - Phone:517-574-5015
Practice Address - Fax:517-574-5362
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist