Provider Demographics
NPI:1013644749
Name:DOMAKONDA, ANVESH (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANVESH
Middle Name:
Last Name:DOMAKONDA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 E STATE HIGHWAY 97
Mailing Address - Street 2:
Mailing Address - City:JOURDANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78026-1521
Mailing Address - Country:US
Mailing Address - Phone:830-770-0770
Mailing Address - Fax:830-770-0973
Practice Address - Street 1:1810 E STATE HIGHWAY 97
Practice Address - Street 2:
Practice Address - City:JOURDANTON
Practice Address - State:TX
Practice Address - Zip Code:78026-1521
Practice Address - Country:US
Practice Address - Phone:830-770-0770
Practice Address - Fax:830-770-0973
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist