Provider Demographics
NPI:1225286362
Name:BOMMAREDDY, RAMAMOHAN
Entity Type:Individual
Prefix:MR
First Name:RAMAMOHAN
Middle Name:
Last Name:BOMMAREDDY
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 1:619 EAST 169 ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456
Mailing Address - Country:US
Mailing Address - Phone:718-620-9000
Mailing Address - Fax:
Practice Address - Street 1:619 EAST 169 ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456
Practice Address - Country:US
Practice Address - Phone:718-620-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025284183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249287Medicaid
NY02249287Medicaid