Provider Demographics
NPI:1336536747
Name:BOPPANA, RAVI
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:
Last Name:BOPPANA
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 1:5452 BLANDING BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-1957
Mailing Address - Country:US
Mailing Address - Phone:904-779-6990
Mailing Address - Fax:904-779-6995
Practice Address - Street 1:5452 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-1957
Practice Address - Country:US
Practice Address - Phone:904-779-6990
Practice Address - Fax:904-779-6995
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist