Provider Demographics
NPI:1407456049
Name:SASTRY, JONNALAGADDA S
Entity Type:Individual
Prefix:
First Name:JONNALAGADDA
Middle Name:S
Last Name:SASTRY
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 1:7 QUELET CT
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-1551
Mailing Address - Country:US
Mailing Address - Phone:410-206-4655
Mailing Address - Fax:
Practice Address - Street 1:6400A RIDGE RD STE 1
Practice Address - Street 2:
Practice Address - City:SYKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21784-6272
Practice Address - Country:US
Practice Address - Phone:410-549-5491
Practice Address - Fax:410-549-5493
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14129183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist