Provider Demographics
NPI:1245661032
Name:BANOTH, PAVAN KUMAR
Entity type:Individual
Prefix:
First Name:PAVAN KUMAR
Middle Name:
Last Name:BANOTH
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 1:3657 SILVER BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-4237
Mailing Address - Country:US
Mailing Address - Phone:904-314-3288
Mailing Address - Fax:
Practice Address - Street 1:3538 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-5253
Practice Address - Country:US
Practice Address - Phone:904-778-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist