1144674193 NPI number — PAVAN PUTRA PHARMACY INC

Table of content: (NPI 1144674193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144674193 NPI number — PAVAN PUTRA PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAVAN PUTRA PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
APOLLO PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144674193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
418 W BROUGHTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31401-3218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-999-6101
Provider Business Mailing Address Fax Number:
912-777-5953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
418 W BROUGHTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31401-3218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-999-6101
Provider Business Practice Location Address Fax Number:
912-777-5953
Provider Enumeration Date:
04/15/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
KAUSHAL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, PIC, AO
Authorized Official Telephone Number:
912-999-6101

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHRE010288 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2159627 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 003176661A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".