Healthcare Provider Details

I. General information

NPI: 1013043413
Provider Name (Legal Business Name): SRISAI RX MART LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 W SAGINAW RD
SANFORD MI
48657-9206
US

IV. Provider business mailing address

28 W SAGINAW RD
SANFORD MI
48657-9206
US

V. Phone/Fax

Practice location:
  • Phone: 989-687-2612
  • Fax: 989-687-5596
Mailing address:
  • Phone: 989-687-2612
  • Fax: 989-687-5596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301010291
License Number StateMI

VIII. Authorized Official

Name: SIVA JONNALGADA
Title or Position: MANAGER
Credential:
Phone: 732-494-0458