Provider Demographics
NPI:1023254646
Name:GORANTLA, RAJA S (RPH)
Entity type:Individual
Prefix:
First Name:RAJA
Middle Name:S
Last Name:GORANTLA
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 1:408 BLOOMING GROVE TPKE
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-7841
Mailing Address - Country:US
Mailing Address - Phone:845-561-5555
Mailing Address - Fax:845-561-7571
Practice Address - Street 1:408 BLOOMING GROVE TPKE
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-7841
Practice Address - Country:US
Practice Address - Phone:845-561-5555
Practice Address - Fax:845-561-7571
Is Sole Proprietor?:No
Enumeration Date:2009-01-02
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY026389OtherNY BOARD OF PHARMACY
NY02498704Medicaid
3376440OtherNABP
NY1720185663OtherPHARMACY NPI
NY5186230001Medicare NSC