Provider Demographics
NPI:1184228983
Name:BOMMANA, CHETANA MANTRI
Entity type:Individual
Prefix:
First Name:CHETANA
Middle Name:MANTRI
Last Name:BOMMANA
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 1:9856 MONTCLAIR CIR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-1966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1239 SR 436
Practice Address - Street 2:UNIT 101
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707
Practice Address - Country:US
Practice Address - Phone:407-679-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist