Provider Demographics
NPI:1295067858
Name:VENIGALLA, SAMBASIVA R (RPH)
Entity type:Individual
Prefix:MR
First Name:SAMBASIVA
Middle Name:R
Last Name:VENIGALLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:178 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-5951
Mailing Address - Country:US
Mailing Address - Phone:631-957-9723
Mailing Address - Fax:631-957-9710
Practice Address - Street 1:178 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-5951
Practice Address - Country:US
Practice Address - Phone:631-957-9723
Practice Address - Fax:631-957-9710
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY032800-1OtherNEW YORK STATE PHARMACIST LICENSE NUMBER