Healthcare Provider Details

I. General information

NPI: 1063448280
Provider Name (Legal Business Name): SIRISANSH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 03/11/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 SHERMAN DR. STE. 1
RIVERSIDE CA
92503
US

IV. Provider business mailing address

3838 SHERMAN DR. STE. 1
RIVERSIDE CA
92503
US

V. Phone/Fax

Practice location:
  • Phone: 951-687-4203
  • Fax: 909-687-1145
Mailing address:
  • Phone: 951-687-4203
  • Fax: 909-687-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number55696
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SIRISHA PALAVALLI
Title or Position: MANAGER MEMBER
Credential:
Phone: 951-687-4203