Provider Demographics
NPI:1457635617
Name:BANDEKAR, TINA U
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:U
Last Name:BANDEKAR
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:UJWALA
Other - Middle Name:
Other - Last Name:BANDEKAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5852 N ROTHMANS AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0927
Mailing Address - Country:US
Mailing Address - Phone:208-794-8755
Mailing Address - Fax:
Practice Address - Street 1:10530 W CARLTON BAY DR
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-5111
Practice Address - Country:US
Practice Address - Phone:208-319-2482
Practice Address - Fax:208-319-2488
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist