Provider Demographics
NPI:1538316013
Name:KAVURU, VIMAL (RPH)
Entity type:Individual
Prefix:
First Name:VIMAL
Middle Name:
Last Name:KAVURU
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 1:828 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4403
Mailing Address - Country:US
Mailing Address - Phone:718-493-8833
Mailing Address - Fax:718-604-1392
Practice Address - Street 1:828 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4403
Practice Address - Country:US
Practice Address - Phone:718-493-8833
Practice Address - Fax:718-604-1392
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042732183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02078173Medicaid
4018010001Medicare NSC