MEDICARE: DR. SRIDHAR BALASUBRAMANYAN RPH, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PH 00071904	WA
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PH00071904	WA

General Provider Information

NPI Number	:	1255605820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SRIDHAR BALASUBRAMANYAN RPH, PHD

Provider Business Mailing Address
First Line	:	19955 STATE ROUTE 2
Second Line	:
City	:	MONROE
State	:	WA
Zip	:	98272-2338
Country	:	US
Telephone Number	:	360-926-0391
Fax Number	:	360-925-3290

Provider Business Practice Location Address
First Line	:	19955 STATE ROUTE 2
Second Line	:
City	:	MONROE
State	:	WA
Zip	:	98272-2338
Country	:	US
Telephone Number	:	360-926-0391
Fax Number	:	360-925-3290

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/29/2012
Last Update Date	:	04/20/2026

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