Provider Demographics
NPI:1457726663
Name:PERIYASAMY THANDAVAN, SUDHARSAN (PHD)
Entity Type:Individual
Prefix:
First Name:SUDHARSAN
Middle Name:
Last Name:PERIYASAMY THANDAVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2218
Mailing Address - Country:US
Mailing Address - Phone:706-733-4277
Mailing Address - Fax:
Practice Address - Street 1:2744 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-2218
Practice Address - Country:US
Practice Address - Phone:706-733-4277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0287051835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAUIJ945A15732OtherBLUECROSS BLUESHEILD