Provider Demographics
NPI:1861905689
Name:MANDAVA, MURALI
Entity type:Individual
Prefix:
First Name:MURALI
Middle Name:
Last Name:MANDAVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6307 MEADOWVIEW DR
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-7262
Mailing Address - Country:US
Mailing Address - Phone:412-526-0802
Mailing Address - Fax:
Practice Address - Street 1:1930 W GRAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-4870
Practice Address - Country:US
Practice Address - Phone:417-863-6416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007025913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist