Provider Demographics
NPI:1710580055
Name:RAMESH, PRASAD SHIVA (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:PRASAD
Middle Name:SHIVA
Last Name:RAMESH
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WALMART PHARMACY
Mailing Address - Street 2:4096 NORTH FOSTER ROAD
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244
Mailing Address - Country:US
Mailing Address - Phone:210-507-4962
Mailing Address - Fax:210-507-4963
Practice Address - Street 1:4096 N FOSTER RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-1874
Practice Address - Country:US
Practice Address - Phone:210-507-4962
Practice Address - Fax:210-507-4963
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX52211OtherRPH LICENSE NUMBER
TX1447590625Medicaid