Provider Demographics
NPI:1609145861
Name:VASIREDDY, MAHITHA
Entity Type:Individual
Prefix:
First Name:MAHITHA
Middle Name:
Last Name:VASIREDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 FIELDS SOUTH DR
Mailing Address - Street 2:APT 207
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-3708
Mailing Address - Country:US
Mailing Address - Phone:708-955-5756
Mailing Address - Fax:
Practice Address - Street 1:1509 S NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-6531
Practice Address - Country:US
Practice Address - Phone:217-351-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-16
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist