Provider Demographics
NPI:1396863221
Name:GUMMELLA, JAGADEESH (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAGADEESH
Middle Name:
Last Name:GUMMELLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-7800
Mailing Address - Country:US
Mailing Address - Phone:212-254-7307
Mailing Address - Fax:212-254-7352
Practice Address - Street 1:273 E 3RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-7800
Practice Address - Country:US
Practice Address - Phone:212-254-7307
Practice Address - Fax:212-254-7352
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047742183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02197560Medicaid