Provider Demographics
NPI:1457643058
Name:DONTAM, THIRUPATHI REDDY
Entity Type:Individual
Prefix:MR
First Name:THIRUPATHI
Middle Name:REDDY
Last Name:DONTAM
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 1:161 NE RIFLE RANGE ST
Mailing Address - Street 2:APT#58
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-5914
Mailing Address - Country:US
Mailing Address - Phone:541-672-4896
Mailing Address - Fax:
Practice Address - Street 1:161 NE RIFLE RANGE ST
Practice Address - Street 2:APT#58
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-5914
Practice Address - Country:US
Practice Address - Phone:541-672-4896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-15
Last Update Date:2011-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00124441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist