Provider Demographics
NPI:1215578836
Name:BISTA, SOVIT
Entity Type:Individual
Prefix:
First Name:SOVIT
Middle Name:
Last Name:BISTA
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 1:618 ACADIA BND
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2195
Mailing Address - Country:US
Mailing Address - Phone:304-237-3041
Mailing Address - Fax:
Practice Address - Street 1:1139 W BRAKER LN STE 102
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-4113
Practice Address - Country:US
Practice Address - Phone:512-206-3150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65686183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist