Provider Demographics
NPI:1487930715
Name:POTLURI, KALYANI
Entity type:Individual
Prefix:
First Name:KALYANI
Middle Name:
Last Name:POTLURI
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 1:32320 STATE HIGHWAY 249
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:TX
Mailing Address - Zip Code:77362-3892
Mailing Address - Country:US
Mailing Address - Phone:832-934-0415
Mailing Address - Fax:832-934-2095
Practice Address - Street 1:32320 STATE HIGHWAY 249
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:TX
Practice Address - Zip Code:77362-3892
Practice Address - Country:US
Practice Address - Phone:832-934-0415
Practice Address - Fax:832-934-2095
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist