Provider Demographics
NPI:1063704732
Name:BASAVARAJ, SURESH (PHARMACIST)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:BASAVARAJ
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 E YELM AVE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-9425
Mailing Address - Country:US
Mailing Address - Phone:360-458-9011
Mailing Address - Fax:
Practice Address - Street 1:909 E YELM AVE
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-9425
Practice Address - Country:US
Practice Address - Phone:360-458-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60020887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist