Provider Demographics
NPI:1902104748
Name:PANCHAKARLA, SWARNA LATHA
Entity Type:Individual
Prefix:MRS
First Name:SWARNA
Middle Name:LATHA
Last Name:PANCHAKARLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 RIVENDELL WAY
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2008
Mailing Address - Country:US
Mailing Address - Phone:732-986-1834
Mailing Address - Fax:
Practice Address - Street 1:139 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-1901
Practice Address - Country:US
Practice Address - Phone:973-275-3845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02936100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist