Provider Demographics
NPI:1609288067
Name:GANDHAM, SANTOSH KUMAR
Entity Type:Individual
Prefix:
First Name:SANTOSH
Middle Name:KUMAR
Last Name:GANDHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 W GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-8323
Mailing Address - Country:US
Mailing Address - Phone:602-336-4590
Mailing Address - Fax:602-336-9954
Practice Address - Street 1:3440 W GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-8323
Practice Address - Country:US
Practice Address - Phone:602-336-4590
Practice Address - Fax:602-336-9954
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS015080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist