Provider Demographics
NPI:1225246309
Name:TALLA, SRINIVASA R
Entity Type:Individual
Prefix:MR
First Name:SRINIVASA
Middle Name:R
Last Name:TALLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 N PLANK RD
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-2118
Mailing Address - Country:US
Mailing Address - Phone:845-561-3784
Mailing Address - Fax:
Practice Address - Street 1:39 N PLANK RD
Practice Address - Street 2:SUITE # 2
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-2118
Practice Address - Country:US
Practice Address - Phone:845-561-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist