Healthcare Provider Details

I. General information

NPI: 1275673204
Provider Name (Legal Business Name): SHANMUKHI REDDY RAGI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550969 US HIGHWAY 1
HILLIARD FL
32046-8296
US

IV. Provider business mailing address

2001 CHAUCER LN
PONTE VEDRA BEACH FL
32081
US

V. Phone/Fax

Practice location:
  • Phone: 904-845-7199
  • Fax: 904-845-3348
Mailing address:
  • Phone: 904-845-7199
  • Fax: 904-845-3348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS41200
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: