Provider Demographics
NPI:1720478241
Name:VITTALA, BHARGAVI
Entity Type:Individual
Prefix:
First Name:BHARGAVI
Middle Name:
Last Name:VITTALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BHARGAVI
Other - Middle Name:
Other - Last Name:MAMIDALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:46201 POTOMAC RUN PLZ
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-6609
Mailing Address - Country:US
Mailing Address - Phone:703-444-8440
Mailing Address - Fax:
Practice Address - Street 1:46201 POTOMAC RUN PLZ
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-6609
Practice Address - Country:US
Practice Address - Phone:703-444-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230009693183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician