Basic Information
| Provider Information | |||||||||
| NPI: | 1407456049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SASTRY | ||||||||
| FirstName: | JONNALAGADDA | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 QUELET CT | ||||||||
| Address2: | |||||||||
| City: | NOTTINGHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212361551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102064655 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6400A RIDGE RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | SYKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217846272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105495491 | ||||||||
| FaxNumber: | 4105495493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2020 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 14129 | MD | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.