Provider Demographics
NPI:1881297604
Name:KUCHIBHOTLA, RAVI M
Entity type:Individual
Prefix:
First Name:RAVI
Middle Name:M
Last Name:KUCHIBHOTLA
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 1:8580 HIGHWAY 72 W
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-9578
Mailing Address - Country:US
Mailing Address - Phone:256-716-6958
Mailing Address - Fax:
Practice Address - Street 1:8580 HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9578
Practice Address - Country:US
Practice Address - Phone:256-716-6958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21037183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist