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General NPI Number Information
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NPI Number | 1053916247
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Entity Type | Individual
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Provider Name | SHESHA SIVARAMA PRAS LAKKARAJU VENKATA
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Gender | Male
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Dates
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Enumeration Date | 12/03/2020
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Last Update Date | 12/03/2020
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Provider Practice Location Address
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Address Line | 1605 S 31 ST SUITE 19
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City | TEMPLE
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State | TX
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Zip | 76508-0001
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Country | US
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Telephone | 254-215-9100
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Fax | 254-215-9106
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Provider Business Mailing Address
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Address Line | 12370 ALAMEDA TRACE CIR APT 1223
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City | AUSTIN
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State | TX
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Zip | 78727-6456
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Country | US
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Telephone | 608-201-4056
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 64353
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License Number State | TX
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