Provider Demographics
NPI:1114476819
Name:BAVIRISETTY, SRIDEVI
Entity Type:Individual
Prefix:MRS
First Name:SRIDEVI
Middle Name:
Last Name:BAVIRISETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 MOSSER RD
Mailing Address - Street 2:APT F204
Mailing Address - City:BREINIGSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18031
Mailing Address - Country:US
Mailing Address - Phone:609-915-4999
Mailing Address - Fax:
Practice Address - Street 1:1063 MOSSER RD
Practice Address - Street 2:APT F204
Practice Address - City:BREINIGSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18031
Practice Address - Country:US
Practice Address - Phone:609-915-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041050183500000X
PA450153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist