Healthcare Provider Details

I. General information

NPI: 1376608703
Provider Name (Legal Business Name): SRI SRINIVASA PHARMA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 OCEAN AVE
JERSEY CITY NJ
07305
US

IV. Provider business mailing address

119 OCEAN AVE
JERSEY CITY NJ
07305
US

V. Phone/Fax

Practice location:
  • Phone: 201-432-6968
  • Fax: 201-432-7004
Mailing address:
  • Phone: 201-432-6968
  • Fax: 201-432-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00618300
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SUDHEER MALGIREDDY
Title or Position: OWNER
Credential:
Phone: 347-307-1421