Provider Demographics
NPI:1831841659
Name:SIVAPRAKASAM, SHASHIKALA NILMINI
Entity type:Individual
Prefix:
First Name:SHASHIKALA
Middle Name:NILMINI
Last Name:SIVAPRAKASAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 JAMESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1975
Mailing Address - Country:US
Mailing Address - Phone:304-610-2168
Mailing Address - Fax:
Practice Address - Street 1:100 21ST ST
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1740
Practice Address - Country:US
Practice Address - Phone:304-755-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist