Provider Demographics
NPI:1407332521
Name:RAGHUNANDAN, GIRA
Entity Type:Individual
Prefix:
First Name:GIRA
Middle Name:
Last Name:RAGHUNANDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10405 N CENTERWAY DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1233
Mailing Address - Country:US
Mailing Address - Phone:309-621-7342
Mailing Address - Fax:309-621-7343
Practice Address - Street 1:10405 N CENTERWAY DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1233
Practice Address - Country:US
Practice Address - Phone:309-621-7342
Practice Address - Fax:309-621-7343
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051291080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist