Healthcare Provider Details

I. General information

NPI: 1912477597
Provider Name (Legal Business Name): GANESHAN S IYER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GANESHAN IYER

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26075 RIDGE RD
DAMASCUS MD
20872-1831
US

IV. Provider business mailing address

14916 TALKING ROCK CT
NORTH POTOMAC MD
20878
US

V. Phone/Fax

Practice location:
  • Phone: 301-253-9418
  • Fax:
Mailing address:
  • Phone: 301-706-8382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17378
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: