Provider Demographics
NPI:1841447299
Name:MADAMALA, NARAYANARAO
Entity type:Individual
Prefix:
First Name:NARAYANARAO
Middle Name:
Last Name:MADAMALA
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 1:2803 FEDERAL CT
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-1051
Mailing Address - Country:US
Mailing Address - Phone:815-356-6434
Mailing Address - Fax:
Practice Address - Street 1:HINES CONSOLIDATED MAIL OUT PHARMACY
Practice Address - Street 2:BUILDING 37NW
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:708-786-7820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist