Healthcare Provider Details

I. General information

NPI: 1912334343
Provider Name (Legal Business Name): SRISIRI PHARMA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 FORT ST INDEX PARK PHARMACY
LINCOLN PARK MI
48146-2671
US

IV. Provider business mailing address

190 HADSELL DR
BLOOMFIELD HILLS MI
48302-0408
US

V. Phone/Fax

Practice location:
  • Phone: 313-357-7500
  • Fax: 313-347-8998
Mailing address:
  • Phone: 248-953-2331
  • Fax: 313-447-1688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010202
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KHAJENDRANATH ATLURI
Title or Position: AGENT
Credential:
Phone: 248-953-2331