Provider Demographics
NPI:1376608703
Name:SRI SRINIVASA PHARMA INC
Entity Type:Organization
Organization Name:SRI SRINIVASA PHARMA INC
Other - Org Name:HEALTH CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUDHEER
Authorized Official - Middle Name:
Authorized Official - Last Name:MALGIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-307-1421
Mailing Address - Street 1:119 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305
Mailing Address - Country:US
Mailing Address - Phone:201-432-6968
Mailing Address - Fax:201-432-7004
Practice Address - Street 1:119 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305
Practice Address - Country:US
Practice Address - Phone:201-432-6968
Practice Address - Fax:201-432-7004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SRI SRINIVASA PHARMA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-26
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
NJ28RS006183003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2057958OtherPK
NJ9092501Medicaid
NJ9092501Medicaid