Provider Demographics
NPI:1407188451
Name:JAI SIDDHI VINAYAK INC.
Entity Type:Organization
Organization Name:JAI SIDDHI VINAYAK INC.
Other - Org Name:M L K PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHRADDHA
Authorized Official - Middle Name:NARENDRA
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-757-0262
Mailing Address - Street 1:1489 NEW WALKERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3319
Mailing Address - Country:US
Mailing Address - Phone:336-722-0077
Mailing Address - Fax:336-722-0051
Practice Address - Street 1:1489 NEW WALKERTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3319
Practice Address - Country:US
Practice Address - Phone:336-757-0262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6415090001Medicare NSC