Provider Demographics
NPI:1144774183
Name:RA, SI
Entity Type:Individual
Prefix:
First Name:SI
Middle Name:
Last Name:RA
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 1:3125 STATE ROUTE 27
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08823-1303
Mailing Address - Country:US
Mailing Address - Phone:732-398-3807
Mailing Address - Fax:
Practice Address - Street 1:3125 STATE ROUTE 27
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:NJ
Practice Address - Zip Code:08823-1303
Practice Address - Country:US
Practice Address - Phone:732-398-3807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03798800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist