Healthcare Provider Details

I. General information

NPI: 1477311769
Provider Name (Legal Business Name): SURAJ RIBADIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 N 63RD ST
PHILADELPHIA PA
19151-3209
US

IV. Provider business mailing address

405 SLEIGH HILL RD
NORTHVALE NJ
07647-1328
US

V. Phone/Fax

Practice location:
  • Phone: 215-879-1663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04352100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP458336
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: