Provider Demographics
NPI:1871877423
Name:BANTIWALU, SABEK
Entity type:Individual
Prefix:
First Name:SABEK
Middle Name:
Last Name:BANTIWALU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8414 OLD KEENE MILL RD
Mailing Address - Street 2:UNIT A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2302
Mailing Address - Country:US
Mailing Address - Phone:703-913-6712
Mailing Address - Fax:703-913-6718
Practice Address - Street 1:8414 OLD KEENE MILL RD
Practice Address - Street 2:UNIT A
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-2302
Practice Address - Country:US
Practice Address - Phone:703-913-6712
Practice Address - Fax:703-913-6718
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209459183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist