=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487990271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITADEL INFUSION SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2012
-----------------------------------------------------
Last Update Date | 12/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 NEW MARKET PKWY SE STE 126
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-9309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-541-1910
-----------------------------------------------------
Fax | 770-541-1916
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 NEW MARKET PKWY SE SUITE 126
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-9315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-541-1910
-----------------------------------------------------
Fax | 770-541-1916
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SRIDEVI KATRAGADDDA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-247-9389
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336H0001X
-----------------------------------------------------
Taxonomy Name | Home Infusion Therapy Pharmacy
-----------------------------------------------------
License Number | PHRE009889
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------