MEDICARE: SAMATHA SHASHI RAVI RUDRANGI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	66452	TX

General Provider Information

NPI Number	:	1194452821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMATHA SHASHI RAVI RUDRANGI

Provider Business Mailing Address
First Line	:	2602 N MAIN AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-2919
Country	:	US
Telephone Number	:	210-736-3161
Fax Number	:	210-736-3175

Provider Business Practice Location Address
First Line	:	2602 N MAIN AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-2919
Country	:	US
Telephone Number	:	210-736-3161
Fax Number	:	210-736-3175

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2022
Last Update Date	:	08/03/2022

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