Provider Demographics
NPI:1104189984
Name:GANGIREDDY, MADHAVI L
Entity Type:Individual
Prefix:
First Name:MADHAVI
Middle Name:L
Last Name:GANGIREDDY
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 1:1983 OAKWELL FARMS PKWY
Mailing Address - Street 2:605
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-1724
Mailing Address - Country:US
Mailing Address - Phone:432-599-0394
Mailing Address - Fax:
Practice Address - Street 1:3300 N MIDLAND DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-4601
Practice Address - Country:US
Practice Address - Phone:432-599-0394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX023370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist