Provider Demographics
NPI:1174113302
Name:LATTUPALLY, CHAKRADHARA
Entity type:Individual
Prefix:
First Name:CHAKRADHARA
Middle Name:
Last Name:LATTUPALLY
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 1:2028 RIO SAMBA
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4915
Mailing Address - Country:US
Mailing Address - Phone:586-873-2477
Mailing Address - Fax:
Practice Address - Street 1:2207 S ZARZAMORA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-8024
Practice Address - Country:US
Practice Address - Phone:210-223-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47467183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist