Healthcare Provider Details

I. General information

NPI: 1790553352
Provider Name (Legal Business Name): SRIVARSHINI KANUKOLLU PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

5 ELMCREST CT
MONROE NJ
08831-3811
US

V. Phone/Fax

Practice location:
  • Phone: 347-798-9213
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number069248
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number069248
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: