Provider Demographics
NPI:1902567027
Name:KODALI, REVATHI
Entity Type:Individual
Prefix:
First Name:REVATHI
Middle Name:
Last Name:KODALI
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 1:3860 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-1307
Mailing Address - Country:US
Mailing Address - Phone:414-282-7557
Mailing Address - Fax:
Practice Address - Street 1:3860 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-1307
Practice Address - Country:US
Practice Address - Phone:414-282-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21178-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist