Healthcare Provider Details

I. General information

NPI: 1134405194
Provider Name (Legal Business Name): SRINIVASA RAO BANDARUPALLI R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2011
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9741 DIXIE HWY
CLARKSTON MI
48348-4145
US

IV. Provider business mailing address

9741 DIXIE HWY
CLARKSTON MI
48348-4145
US

V. Phone/Fax

Practice location:
  • Phone: 248-922-0468
  • Fax: 248-922-0838
Mailing address:
  • Phone: 248-442-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302035966
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: