Provider Demographics
NPI:1558693796
Name:GOPALAIAH, MAHESH (RPH)
Entity Type:Individual
Prefix:MR
First Name:MAHESH
Middle Name:
Last Name:GOPALAIAH
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 1:4540 LACEY BLVD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5719
Mailing Address - Country:US
Mailing Address - Phone:306-438-2353
Mailing Address - Fax:
Practice Address - Street 1:4540 LACEY BLVD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5719
Practice Address - Country:US
Practice Address - Phone:306-438-2353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00058690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist