MEDICARE: MR. GAUTAM THAKKAR RPH

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	PU6132	FL

General Provider Information

NPI Number	:	1194914572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GAUTAM THAKKAR RPH

Provider Business Mailing Address
First Line	:	19107 HARBOR COVE CT
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33558-9702
Country	:	US
Telephone Number	:	813-454-3500
Fax Number	:	352-610-4349

Provider Business Practice Location Address
First Line	:	19107 HARBOR COVE CT
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33558-9702
Country	:	US
Telephone Number	:	813-454-3500
Fax Number	:	813-856-4545

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

Provider Enumeration Date	:	10/22/2007
Last Update Date	:	05/11/2022

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