Provider Demographics
NPI:1932475365
Name:KAMISETTI, RAVICHANDRA
Entity Type:Individual
Prefix:MR
First Name:RAVICHANDRA
Middle Name:
Last Name:KAMISETTI
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 1:1860 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1578
Mailing Address - Country:US
Mailing Address - Phone:509-488-9324
Mailing Address - Fax:509-488-9433
Practice Address - Street 1:1860 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1578
Practice Address - Country:US
Practice Address - Phone:509-488-9324
Practice Address - Fax:509-488-9433
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2014-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60002470183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist