Provider Demographics
NPI:1871144899
Name:ILANGOVAN, SIDDARTHAN (MPHARM, RPH)
Entity type:Individual
Prefix:
First Name:SIDDARTHAN
Middle Name:
Last Name:ILANGOVAN
Suffix:
Gender:M
Credentials:MPHARM, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SAINT CLAIR LN
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-7900
Mailing Address - Country:US
Mailing Address - Phone:304-222-3064
Mailing Address - Fax:
Practice Address - Street 1:360 MOUNT GAY RD
Practice Address - Street 2:BYPASS PHARMACY # 6
Practice Address - City:MOUNT GAY
Practice Address - State:WV
Practice Address - Zip Code:25637
Practice Address - Country:US
Practice Address - Phone:304-752-1445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00050913183500000X
WVRP0006641183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist