Provider Demographics
NPI:1720460017
Name:GOTTIPATI, SRIDHAR (RPH)
Entity Type:Individual
Prefix:MR
First Name:SRIDHAR
Middle Name:
Last Name:GOTTIPATI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10072 SOUTHERN AVE.
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306
Mailing Address - Country:US
Mailing Address - Phone:910-484-0159
Mailing Address - Fax:910-484-3270
Practice Address - Street 1:10072 SOUTHERN AVE.
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306
Practice Address - Country:US
Practice Address - Phone:910-484-0159
Practice Address - Fax:910-484-3270
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19466183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist