Provider Demographics
NPI:1982227880
Name:SUNDARARAJ, GERARDINE
Entity Type:Individual
Prefix:
First Name:GERARDINE
Middle Name:
Last Name:SUNDARARAJ
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 1:1689 GREAT BASIN BLVD
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89301-3154
Mailing Address - Country:US
Mailing Address - Phone:775-289-2671
Mailing Address - Fax:
Practice Address - Street 1:1689 GREAT BASIN BLVD
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-3154
Practice Address - Country:US
Practice Address - Phone:775-289-2671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist