=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447851217
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GANGADHARAM GALLA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2020
-----------------------------------------------------
Last Update Date | 11/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 DANIEL MCCALL DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-7129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-639-2275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2225 GULFSTREAM DR
-----------------------------------------------------
City | LITTLE ELM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75068-5978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 47347
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------