Provider Demographics
NPI:1851668933
Name:HARIDAS, DEEPA
Entity Type:Individual
Prefix:
First Name:DEEPA
Middle Name:
Last Name:HARIDAS
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 1:4001 BEYER PARK DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-0873
Mailing Address - Country:US
Mailing Address - Phone:209-491-2912
Mailing Address - Fax:209-491-2912
Practice Address - Street 1:3015 FLOYD AVENUE
Practice Address - Street 2:
Practice Address - City:MMODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:209-551-4867
Practice Address - Fax:209-551-4873
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57723183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist