Provider Demographics
NPI:1467054767
Name:GANGAVALLI, SAI KRISHNA VENKATA (PHARM D)
Entity Type:Individual
Prefix:
First Name:SAI KRISHNA
Middle Name:VENKATA
Last Name:GANGAVALLI
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 MARKET PL
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-7239
Mailing Address - Country:US
Mailing Address - Phone:214-574-4522
Mailing Address - Fax:214-574-5068
Practice Address - Street 1:1635 MARKETPLACE BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063
Practice Address - Country:US
Practice Address - Phone:214-574-4522
Practice Address - Fax:214-574-5068
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist