Provider Demographics
NPI:1275630105
Name:SRI DRUG CENTER PHARMACY LLC
Entity Type:Organization
Organization Name:SRI DRUG CENTER PHARMACY LLC
Other - Org Name:DRUG CENTER PHARMACY #3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SRIDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTIPATI
Authorized Official - Suffix:
Authorized Official - Credentials:BS IN PHARMACY
Authorized Official - Phone:919-986-2547
Mailing Address - Street 1:912 AIRLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3309
Mailing Address - Country:US
Mailing Address - Phone:757-399-6361
Mailing Address - Fax:757-399-1897
Practice Address - Street 1:912 AIRLINE BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3309
Practice Address - Country:US
Practice Address - Phone:757-399-6361
Practice Address - Fax:757-399-1897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201001994333600000X
333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008506591Medicaid
VA8505225Medicaid
4808246OtherOTHER ID NUMBER-COMMERCIAL NUMBER