Provider Demographics
NPI:1508090242
Name:BOMMAREDDY, GITENDRA (RPH)
Entity Type:Individual
Prefix:MR
First Name:GITENDRA
Middle Name:
Last Name:BOMMAREDDY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6608 MARKSTOWN DR APT B
Mailing Address - Street 2:APT # B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-9370
Mailing Address - Country:US
Mailing Address - Phone:813-418-2304
Mailing Address - Fax:
Practice Address - Street 1:12120 MOON LAKE RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-1809
Practice Address - Country:US
Practice Address - Phone:727-856-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-10
Last Update Date:2009-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 44601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist