Provider Demographics
NPI:1982239646
Name:THADAVILA, ANU THANKACHAN
Entity Type:Individual
Prefix:
First Name:ANU
Middle Name:THANKACHAN
Last Name:THADAVILA
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 1:1159 W 36TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3925
Mailing Address - Country:US
Mailing Address - Phone:347-466-1530
Mailing Address - Fax:
Practice Address - Street 1:1159 W 36TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3925
Practice Address - Country:US
Practice Address - Phone:347-466-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH82102183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist