Provider Demographics
NPI:1194127266
Name:GORANTLA, HIMA
Entity type:Individual
Prefix:
First Name:HIMA
Middle Name:
Last Name:GORANTLA
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 1:3721 222ND PL SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-4221
Mailing Address - Country:US
Mailing Address - Phone:360-386-4615
Mailing Address - Fax:360-386-4609
Practice Address - Street 1:4010 172ND ST NE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-8482
Practice Address - Country:US
Practice Address - Phone:360-386-4615
Practice Address - Fax:360-386-4609
Is Sole Proprietor?:No
Enumeration Date:2014-09-20
Last Update Date:2014-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00054737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist