Provider Demographics
NPI:1174741128
Name:GANGADASU, MADHAVI
Entity type:Individual
Prefix:
First Name:MADHAVI
Middle Name:
Last Name:GANGADASU
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 1:45505 ANDES HILLS CT
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35584 GRANDRIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTONHILLS
Practice Address - State:MI
Practice Address - Zip Code:48335
Practice Address - Country:US
Practice Address - Phone:248-474-1717
Practice Address - Fax:248-474-2590
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist