Provider Demographics
NPI:1962787895
Name:AMMANABROLU, VENKATA RAGHAVA
Entity type:Individual
Prefix:
First Name:VENKATA
Middle Name:RAGHAVA
Last Name:AMMANABROLU
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 1:13905 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5486
Mailing Address - Country:US
Mailing Address - Phone:904-268-9025
Mailing Address - Fax:904-268-9460
Practice Address - Street 1:13905 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5486
Practice Address - Country:US
Practice Address - Phone:904-268-9025
Practice Address - Fax:904-268-9460
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36503183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist