Provider Demographics
NPI:1205225984
Name:MEDAMARTHI, LAKSHMI VARDHANI (RPH)
Entity Type:Individual
Prefix:
First Name:LAKSHMI
Middle Name:VARDHANI
Last Name:MEDAMARTHI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 SUTTER AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-4002
Mailing Address - Country:US
Mailing Address - Phone:718-484-8600
Mailing Address - Fax:
Practice Address - Street 1:589 SUTTER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-4002
Practice Address - Country:US
Practice Address - Phone:718-484-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-17
Last Update Date:2015-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY060117OtherNEW YORK STATE BOARD OF PHARMACY