Healthcare Provider Details

I. General information

NPI: 1255605820
Provider Name (Legal Business Name): SRIDHAR BALASUBRAMANYAN RPH, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19955 STATE ROUTE 2
MONROE WA
98272-2338
US

IV. Provider business mailing address

19955 STATE ROUTE 2
MONROE WA
98272-2338
US

V. Phone/Fax

Practice location:
  • Phone: 360-926-0391
  • Fax: 360-925-3290
Mailing address:
  • Phone: 360-926-0391
  • Fax: 360-925-3290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH 00071904
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH00071904
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: