Healthcare Provider Details

I. General information

NPI: 1174113302
Provider Name (Legal Business Name): CHAKRADHARA LATTUPALLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2207 S ZARZAMORA ST
SAN ANTONIO TX
78207-8024
US

IV. Provider business mailing address

2028 RIO SAMBA
SAN ANTONIO TX
78258-4915
US

V. Phone/Fax

Practice location:
  • Phone: 210-223-3863
  • Fax:
Mailing address:
  • Phone: 586-873-2477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number47467
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: