Provider Demographics
NPI:1881298990
Name:KUKKILLAYA, BALAKRISHNA U (RPH)
Entity type:Individual
Prefix:MR
First Name:BALAKRISHNA
Middle Name:U
Last Name:KUKKILLAYA
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 1:6 LYNN PL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2105
Mailing Address - Country:US
Mailing Address - Phone:304-343-4080
Mailing Address - Fax:
Practice Address - Street 1:6 LYNN PL
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2105
Practice Address - Country:US
Practice Address - Phone:304-343-4080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty