Provider Demographics
NPI:1023608031
Name:GUPTA, GAURAV
Entity type:Individual
Prefix:
First Name:GAURAV
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 W DAUGHTERY RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-3293
Mailing Address - Country:US
Mailing Address - Phone:863-272-6391
Mailing Address - Fax:
Practice Address - Street 1:1228 W DAUGHTERY RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-3293
Practice Address - Country:US
Practice Address - Phone:863-272-6391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-23
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist