Provider Demographics
NPI:1689906133
Name:THIMMEGOWDA, SUNIL B
Entity Type:Individual
Prefix:MR
First Name:SUNIL
Middle Name:B
Last Name:THIMMEGOWDA
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 1:2539 MARVIN RD NE STE E
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-3175
Mailing Address - Country:US
Mailing Address - Phone:360-438-3072
Mailing Address - Fax:360-438-3532
Practice Address - Street 1:2539 MARVIN RD NE STE E
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3175
Practice Address - Country:US
Practice Address - Phone:360-438-3072
Practice Address - Fax:360-438-3532
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00053851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031538Medicaid