Provider Demographics
NPI:1760772107
Name:GUMMADI, BHAGYA LAKSHMI
Entity Type:Individual
Prefix:MRS
First Name:BHAGYA
Middle Name:LAKSHMI
Last Name:GUMMADI
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 1:3081 KENILWORTH DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9E4M6
Mailing Address - Country:CA
Mailing Address - Phone:519-966-0419
Mailing Address - Fax:
Practice Address - Street 1:4902 DEWIT RD
Practice Address - Street 2:SUITE # 104
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188
Practice Address - Country:US
Practice Address - Phone:734-398-7796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist