Provider Demographics
NPI:1528382561
Name:DHAMA, BAKTHAVATSALU (RPH)
Entity Type:Individual
Prefix:MR
First Name:BAKTHAVATSALU
Middle Name:
Last Name:DHAMA
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 1:12501 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-1411
Mailing Address - Country:US
Mailing Address - Phone:718-849-7300
Mailing Address - Fax:718-785-3333
Practice Address - Street 1:12501 101ST AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1411
Practice Address - Country:US
Practice Address - Phone:718-849-7300
Practice Address - Fax:718-785-3333
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02617807Medicaid
NY5427640001Medicare NSC