=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669689873
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEKHAR MAMIDI PHARM.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MED CENTER DR
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26301-4155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-623-3461
-----------------------------------------------------
Fax | 304-623-7690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 PIGEON ROOST RD
-----------------------------------------------------
City | CHAPMANVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25508-9502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-216-9957
-----------------------------------------------------
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 | RP0006861
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------