=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932639440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SVI PHARMA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2017
-----------------------------------------------------
Last Update Date | 07/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 ACKERMAN AVE
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-928-3400
-----------------------------------------------------
Fax | 973-928-4010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85 ACKERMAN AVE
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-928-3400
-----------------------------------------------------
Fax | 973-928-4010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER IDEAL MARKETPLACE PHARMACY
-----------------------------------------------------
Name | RAMASWAMY GUMMADI
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 973-928-4576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00756600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------