Basic Information
| Provider Information | |||||||||
| NPI: | 1003193376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KURIAN | ||||||||
| FirstName: | SANTHOSH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 532 SANTA FE TRL | ||||||||
| Address2: | APT# 250 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750634611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729245731 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1701 W SOUTHLAKE BLVD | ||||||||
| Address2: | WALGREENS PHARMACY | ||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760926803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174884978 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2011 | ||||||||
| LastUpdateDate: | 11/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 49210 | TX | Y | Pharmacy Service Providers | Pharmacist | 183500000X | S017720 | AZ | N | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 49210 | 01 | TX | PHARMACIST LICENSE | OTHER | S017720 | 01 | AZ | PHARMACIST LICENSE | OTHER |