Healthcare Provider Details

I. General information

NPI: 1366909657
Provider Name (Legal Business Name): SUSHMA RAO SHIRAVANTHE BS, PHARMD, BCPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 MIRANDA AVE
PALO ALTO CA
94304-1207
US

IV. Provider business mailing address

521 ASPEN PL
EAST PALO ALTO CA
94303-1348
US

V. Phone/Fax

Practice location:
  • Phone: 650-493-5000
  • Fax:
Mailing address:
  • Phone: 248-767-4249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26026674A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number26026674A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26026674A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: