Provider Demographics
NPI:1891882569
Name:MAGISETTY, VENKATA R
Entity Type:Individual
Prefix:MR
First Name:VENKATA
Middle Name:R
Last Name:MAGISETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SANDALWOOD DR NW
Mailing Address - Street 2:APT 5 G
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-6709
Mailing Address - Country:US
Mailing Address - Phone:850-602-0061
Mailing Address - Fax:
Practice Address - Street 1:WINN-DIXIE STORE #0566
Practice Address - Street 2:99 ELGIN PARKWAY NW
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548
Practice Address - Country:US
Practice Address - Phone:850-244-1226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39988183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist