Provider Demographics
NPI:1316547979
Name:GANJI, SAMBA SHIVA V V V PRASAD
Entity Type:Individual
Prefix:
First Name:SAMBA SHIVA
Middle Name:V V V PRASAD
Last Name:GANJI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PRASAD
Other - Middle Name:SSVVV
Other - Last Name:GANJI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2932 SAN PEDRO DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-8629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 HOBBS HWY
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:TX
Practice Address - Zip Code:79360-3039
Practice Address - Country:US
Practice Address - Phone:432-758-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX49469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist