Provider Demographics
NPI:1841417417
Name:RAYATHATHA, SANJAY L (RPH)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:L
Last Name:RAYATHATHA
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 1:8729 LASALLE CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4185
Mailing Address - Country:US
Mailing Address - Phone:410-750-3577
Mailing Address - Fax:
Practice Address - Street 1:4339 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-2143
Practice Address - Country:US
Practice Address - Phone:410-529-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14290183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist