Healthcare Provider Details

I. General information

NPI: 1063608412
Provider Name (Legal Business Name): GNANAVEL MUNIRATHINAM PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 E FREDERICK ST
WALKERSVILLE MD
21793-8234
US

IV. Provider business mailing address

19 E FREDERICK ST
WALKERSVILLE MD
21793-8234
US

V. Phone/Fax

Practice location:
  • Phone: 301-845-4401
  • Fax: 301-845-1114
Mailing address:
  • Phone: 301-845-4401
  • Fax: 301-845-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13915
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: