Provider Demographics
NPI:1699866517
Name:AMBATI, SURESH (RPH)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:AMBATI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N JOSEY LN STE 104
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-6144
Mailing Address - Country:US
Mailing Address - Phone:941-387-4034
Mailing Address - Fax:
Practice Address - Street 1:1110 N JOSEY LN STE 104
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-6144
Practice Address - Country:US
Practice Address - Phone:941-387-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38904183500000X
NJ28R103560100183500000X
NY20 057987183500000X
TX47561183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX47561OtherPHARMACIST
NJ28R103560100OtherPHARMACIST
TX47561OtherPHARMACIST