Provider Demographics
NPI:1063448280
Name:SIRISANSH LLC
Entity Type:Organization
Organization Name:SIRISANSH LLC
Other - Org Name:PARKE VISTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SIRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALAVALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-687-4203
Mailing Address - Street 1:3838 SHERMAN DR.
Mailing Address - Street 2:STE. 1
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503
Mailing Address - Country:US
Mailing Address - Phone:951-687-4203
Mailing Address - Fax:909-687-1145
Practice Address - Street 1:3838 SHERMAN DR.
Practice Address - Street 2:STE. 1
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503
Practice Address - Country:US
Practice Address - Phone:951-687-4203
Practice Address - Fax:909-687-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336M0002X, 3336M0003X, 3336M0003X, 333600000X
CA556963336C0003X
CAPHY420143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA420140Medicaid
1995845OtherPK
1995845OtherPK