Provider Demographics
NPI:1174653927
Name:GONDI, KRISHNA CHAITANYA
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:CHAITANYA
Last Name:GONDI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4674
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-4674
Mailing Address - Country:US
Mailing Address - Phone:928-614-9012
Mailing Address - Fax:928-645-1286
Practice Address - Street 1:650, ELM STREET
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-645-2917
Practice Address - Fax:928-645-1286
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist