Healthcare Provider Details

I. General information

NPI: 1558184184
Provider Name (Legal Business Name): CHANDRA S VATTIKONDA R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 ALCO AVE STE C
DALLAS TX
75211-2614
US

IV. Provider business mailing address

2807 TWIN EAGLES DR
CELINA TX
75009-4699
US

V. Phone/Fax

Practice location:
  • Phone: 214-919-2399
  • Fax: 214-919-2344
Mailing address:
  • Phone: 973-723-4523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number73400
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: