Basic Information
| Provider Information | |||||||||
| NPI: | 1932475365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAMISETTI | ||||||||
| FirstName: | RAVICHANDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094889324 | ||||||||
| FaxNumber: | 5094889433 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094889324 | ||||||||
| FaxNumber: | 5094889433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 07/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH60002470 | WA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.