Provider Demographics
NPI:1356347330
Name:PATHAK, RAVINDRA KUMAR (PHARMD, PHD, BCPS)
Entity type:Individual
Prefix:DR
First Name:RAVINDRA
Middle Name:KUMAR
Last Name:PATHAK
Suffix:
Gender:M
Credentials:PHARMD, PHD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2607
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL DR
Practice Address - Street 2:VA SALT LAKE CITY HCS 119A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11779183500000X, 1835P1200X, 1835P1300X
TX449231835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist