Healthcare Provider Details

I. General information

NPI: 1366703381
Provider Name (Legal Business Name): CHAKRAVARTHY CHALAMALA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 NORTH HIGHWAY 491 SAFEWAY PHARMACY
GALLUP NM
87301
US

IV. Provider business mailing address

910B E GREEN AVE
GALLUP NM
87301-5515
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-9977
  • Fax: 505-722-8481
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007440
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: