Provider Demographics
NPI:1356665731
Name:EDAVALAPATI, SRINIVASA RAO (MPHARM)
Entity Type:Individual
Prefix:MR
First Name:SRINIVASA
Middle Name:RAO
Last Name:EDAVALAPATI
Suffix:
Gender:M
Credentials:MPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4329 BROADWAY
Mailing Address - Street 2:BROADWAY PHARMACY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-2408
Mailing Address - Country:US
Mailing Address - Phone:212-740-8500
Mailing Address - Fax:212-740-9400
Practice Address - Street 1:4329 BROADWAY
Practice Address - Street 2:BROADWAY PHARMACY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-2408
Practice Address - Country:US
Practice Address - Phone:212-740-8500
Practice Address - Fax:212-740-9400
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050398183500000X
NJ28RI02773400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist