Provider Demographics
NPI:1558653774
Name:ELAMANCHILI, PRAVEEN
Entity type:Individual
Prefix:MR
First Name:PRAVEEN
Middle Name:
Last Name:ELAMANCHILI
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:PRAVEEN
Other - Middle Name:
Other - Last Name:ELAMANCHILI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH, PHD
Mailing Address - Street 1:17701 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-4609
Mailing Address - Country:US
Mailing Address - Phone:253-847-2781
Mailing Address - Fax:
Practice Address - Street 1:17701 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-4609
Practice Address - Country:US
Practice Address - Phone:253-847-2781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60107536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist