Provider Demographics
NPI:1760799381
Name:GOTTIMUKKALA, ANIL (RPH)
Entity Type:Individual
Prefix:
First Name:ANIL
Middle Name:
Last Name:GOTTIMUKKALA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4031 EAST HYW 83
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDECITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582
Mailing Address - Country:US
Mailing Address - Phone:956-487-0905
Mailing Address - Fax:956-488-8754
Practice Address - Street 1:4031 EAST HYW 83
Practice Address - Street 2:
Practice Address - City:RIO GRANDECITY
Practice Address - State:TX
Practice Address - Zip Code:78582
Practice Address - Country:US
Practice Address - Phone:956-487-0905
Practice Address - Fax:956-488-8754
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist