Healthcare Provider Details

I. General information

NPI: 1821364837
Provider Name (Legal Business Name): SRINIVASA SURI REPALLE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2012
Last Update Date: 03/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 N STRATFORD RD
MOSES LAKE WA
98837-1574
US

IV. Provider business mailing address

1005 N STRATFORD RD
MOSES LAKE WA
98837-1574
US

V. Phone/Fax

Practice location:
  • Phone: 509-766-0168
  • Fax: 509-766-0741
Mailing address:
  • Phone: 509-766-0168
  • Fax: 509-766-0741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60064746
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: