Provider Demographics
NPI:1316546203
Name:SIDDAGANGAIAH, RAGHUNATH
Entity Type:Individual
Prefix:
First Name:RAGHUNATH
Middle Name:
Last Name:SIDDAGANGAIAH
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 1:520 N 35TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-2120
Mailing Address - Country:US
Mailing Address - Phone:502-776-3765
Mailing Address - Fax:502-776-3939
Practice Address - Street 1:520 N 35TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-2120
Practice Address - Country:US
Practice Address - Phone:502-776-3765
Practice Address - Fax:502-776-3939
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0144061835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist