Provider Demographics
NPI:1063704732
Name:HANUMANAHALLI BASAVARAJ, SURESHA (PHARMACIST)
Entity type:Individual
Prefix:
First Name:SURESHA
Middle Name:
Last Name:HANUMANAHALLI 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 1:1610 NW LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-1711
Mailing Address - Country:US
Mailing Address - Phone:360-740-1876
Mailing Address - Fax:
Practice Address - Street 1:1610 NW LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-1711
Practice Address - Country:US
Practice Address - Phone:360-740-1876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2025-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60020887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist