Provider Demographics
NPI:1093016883
Name:SURESH, SPOORTHY
Entity Type:Individual
Prefix:MRS
First Name:SPOORTHY
Middle Name:
Last Name:SURESH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 6TH CROSS B STREET
Mailing Address - Street 2:GANDHINAGAR
Mailing Address - City:BANGALORE
Mailing Address - State:KARNATAKA
Mailing Address - Zip Code:560009
Mailing Address - Country:IN
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 WILLOW PASS RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519-2544
Practice Address - Country:US
Practice Address - Phone:925-689-0895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60772183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist