Provider Demographics
NPI:1013043413
Name:SRISAI RX MART LLC
Entity Type:Organization
Organization Name:SRISAI RX MART LLC
Other - Org Name:SANFORD FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONNALGADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-494-0458
Mailing Address - Street 1:28 W SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48657-9206
Mailing Address - Country:US
Mailing Address - Phone:989-687-2612
Mailing Address - Fax:989-687-5596
Practice Address - Street 1:28 W SAGINAW RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:MI
Practice Address - Zip Code:48657-9206
Practice Address - Country:US
Practice Address - Phone:989-687-2612
Practice Address - Fax:989-687-5596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010102913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143276OtherPK