Provider Demographics
NPI:1679025456
Name:PASALA, PAULITHA
Entity type:Individual
Prefix:
First Name:PAULITHA
Middle Name:
Last Name:PASALA
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 1:689 MEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1347
Mailing Address - Country:US
Mailing Address - Phone:614-747-6095
Mailing Address - Fax:
Practice Address - Street 1:689 MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1347
Practice Address - Country:US
Practice Address - Phone:631-289-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist