Provider Demographics
NPI:1932408994
Name:GUMUDAVELLI, PEDDANNA (RPH)
Entity Type:Individual
Prefix:
First Name:PEDDANNA
Middle Name:
Last Name:GUMUDAVELLI
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 1:116 NORTHUMBERLAND WAY
Mailing Address - Street 2:APT NO-116
Mailing Address - City:MONMOUTH JUNCTION
Mailing Address - State:NJ
Mailing Address - Zip Code:08852-2345
Mailing Address - Country:US
Mailing Address - Phone:609-712-4510
Mailing Address - Fax:
Practice Address - Street 1:116 NORTHUMBERLAND WAY
Practice Address - Street 2:APT NO-116
Practice Address - City:MONMOUTH JUNCTION
Practice Address - State:NJ
Practice Address - Zip Code:08852-2345
Practice Address - Country:US
Practice Address - Phone:609-712-4510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist