Healthcare Provider Details

I. General information

NPI: 1891624086
Provider Name (Legal Business Name): SRINIVASAN TUPAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 N VETERANS PKWY
BLOOMINGTON IL
61704-0904
US

IV. Provider business mailing address

1525 N VETERANS PKWY
BLOOMINGTON IL
61704-0904
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-8613
  • Fax:
Mailing address:
  • Phone: 309-661-8613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051308316
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: