Provider Demographics
NPI:1871876052
Name:VALLABHANENI, VENKATA S (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:VENKATA
Middle Name:S
Last Name:VALLABHANENI
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46253 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168
Mailing Address - Country:US
Mailing Address - Phone:248-835-8085
Mailing Address - Fax:
Practice Address - Street 1:5505 S OLD US 23
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116
Practice Address - Country:US
Practice Address - Phone:810-229-5466
Practice Address - Fax:810-229-5593
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist