Healthcare Provider Details

I. General information

NPI: 1083996995
Provider Name (Legal Business Name): RAVIKANTH PASALA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3204 PEACH ORCHARD RD
AUGUSTA GA
30906-4862
US

IV. Provider business mailing address

836 SPARKLEBERRY RD
EVANS GA
30809-4407
US

V. Phone/Fax

Practice location:
  • Phone: 706-796-7240
  • Fax:
Mailing address:
  • Phone: 706-631-8328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH25289
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: