Provider Demographics
NPI:1912455833
Name:BHOGANADHAM, SURESH K
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:K
Last Name:BHOGANADHAM
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 1:9406 OAKLEY WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-6024
Mailing Address - Country:US
Mailing Address - Phone:925-768-6292
Mailing Address - Fax:
Practice Address - Street 1:9406 OAKLEY WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-6024
Practice Address - Country:US
Practice Address - Phone:925-768-6292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist