Provider Demographics
NPI:1972156669
Name:SURYADEVARA, PRATAP (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:PRATAP
Middle Name:
Last Name:SURYADEVARA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4995 KIETZKE LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6548
Mailing Address - Country:US
Mailing Address - Phone:775-825-3322
Mailing Address - Fax:775-827-4633
Practice Address - Street 1:6807 EVERGREEN WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-5145
Practice Address - Country:US
Practice Address - Phone:425-438-9380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17999183500000X
WAPH61330362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist