Provider Demographics
NPI:1376867523
Name:WIJEWICKRAMA, THISHANTHI (RPH)
Entity Type:Individual
Prefix:
First Name:THISHANTHI
Middle Name:
Last Name:WIJEWICKRAMA
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:PO BOX 640105
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-0105
Mailing Address - Country:US
Mailing Address - Phone:800-225-5967
Mailing Address - Fax:909-799-4364
Practice Address - Street 1:9717 KEY WEST AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3982
Practice Address - Country:US
Practice Address - Phone:800-225-5967
Practice Address - Fax:909-799-4364
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD19145OtherMD BOARD OF PHARMACY, PHARMACIST LICENSE