Provider Demographics
NPI:1104498732
Name:BHATTARAI, SAMUNDRA
Entity type:Individual
Prefix:
First Name:SAMUNDRA
Middle Name:
Last Name:BHATTARAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2384
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-2384
Mailing Address - Country:US
Mailing Address - Phone:280-602-9226
Mailing Address - Fax:
Practice Address - Street 1:394.3 US-160
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033
Practice Address - Country:US
Practice Address - Phone:928-697-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0134475183500000X
NHPHCY-01155183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHPHCY-01155OtherPHARMACY LICENSE
VT033.0134475OtherLICENSE