Provider Demographics
NPI:1104222488
Name:GANGISETTI, MASTAN RAMPRASAD (RPH)
Entity Type:Individual
Prefix:MR
First Name:MASTAN RAMPRASAD
Middle Name:
Last Name:GANGISETTI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-2174
Mailing Address - Country:US
Mailing Address - Phone:509-248-3855
Mailing Address - Fax:509-452-5203
Practice Address - Street 1:1600 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-2174
Practice Address - Country:US
Practice Address - Phone:509-248-3855
Practice Address - Fax:509-452-5203
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60097582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH60097582OtherPHARMACIST LICENSE