Provider Demographics
NPI:1831634757
Name:RAO, BANSARI
Entity Type:Individual
Prefix:
First Name:BANSARI
Middle Name:
Last Name:RAO
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 1:23403 ROBINBROOK PL
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2635
Mailing Address - Country:US
Mailing Address - Phone:909-263-3259
Mailing Address - Fax:
Practice Address - Street 1:1540 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3653
Practice Address - Country:US
Practice Address - Phone:909-920-0942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist