Provider Demographics
NPI:1134295207
Name:S & R PHARMACY LLC
Entity Type:Organization
Organization Name:S & R PHARMACY LLC
Other - Org Name:FULLER MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:POTLURI
Authorized Official - Suffix:
Authorized Official - Credentials:BPHARM
Authorized Official - Phone:410-574-1440
Mailing Address - Street 1:6918 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3854
Mailing Address - Country:US
Mailing Address - Phone:410-574-1440
Mailing Address - Fax:410-574-1970
Practice Address - Street 1:6918 RIDGE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3854
Practice Address - Country:US
Practice Address - Phone:410-574-1440
Practice Address - Fax:410-574-1970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MDP058233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138118OtherPK